Coronary Artery Bypass Graft Surgery Using the Radial Artery, Right Internal Thoracic Artery, or Saphenous Vein as the Second Conduit.

BACKGROUND: It is not clear whether radial artery (RA), right internal thoracic artery (RITA), or saphenous vein (SV) is the preferred second bypass graft during coronary artery bypass graft surgery using the left internal thoracic artery (LITA) in patients aged less or greater than 70 years. METHODS: Late survival data were collected for 13,324 consecutive, isolated, primary coronary artery bypass graft surgery patients from three hospitals. Cox regression analysis was performed on all patients grouped by age. RESULTS: Adjusted Cox regression showed overall better RA versus SV survival (hazard ratio [HR] 0.82, p < 0.001) and no difference in RITA versus SV survival (HR 0.95, p = 0.35). However, the survival benefit of RA versus SV was seen only in patients aged less than 70 years (HR 0.77, p < 0.001); and RITA patients aged less than 70 years also had a survival benefit compared with SV (HR 0.86, p = 0.03). There was no difference in survival for RA versus RITA across all ages. CONCLUSIONS: For patients aged less than 70 years, the optimal grafting strategy is using either RA or RITA as the second preferred graft. In patients aged 70 years or more, RA and RITA grafting should be used selectively. Multiple arterial grafting using either RA or RITA should be more widely utilized during coronary artery bypass graft surgery for patients less than 70 years of age.

Echocardiography and Cardiac Rupture: Is Contrast Extravasation an Indication for Surgery?

Contrast echocardiography demonstrating microbubbles in the pericardial space has often been cited as evidence of ventricular rupture requiring emergent surgical intervention. We report a case where no myocardial perforation was found during post-myocardial infarction surgery despite prior echocardiographic evidence of contrast extravasation into the pericardial effusion. Clinical decision making requires balancing imaging evidence with clinical circumstances to determine the optimal timing for surgical intervention.

Multiple arterial bypass grafting should be routine.

OBJECTIVE: We sought to estimate the reduction in deaths and the number of additional person-years of life that could potentially be gained by nationwide adoption of routine multiple arterial bypass grafting (MABG). METHODS: Propensity matching on 4883 patients undergoing primary, isolated coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA) from January 1995 to June 2011, resulted in 1023 matched pairs of LITA-radial artery and LITA-saphenous vein patients. Kaplan-Meier estimated survivals were used to calculate the potential number of lives that could be saved based on a 20% and an 80% rate of MABG, compared with the national 10% rate, when applied to a hypothetical national sample of 200,000 similar patients. RESULTS: Our overall MABG rate was 40% with >80% rate for the past 3 years. Kaplan-Meier estimated 10-year survival was better for LITA-radial artery patients (83.1%) compared with LITA-saphenous vein patients (75.7%) (log rank test, P < .001). When compared with the current national 10% MABG rate, a 20% and an 80% MABG rate could potentially result in 1400 and 10,000 fewer annual deaths, respectively, among a hypothetical national cohort, yielding >9000 and >64,000 person-years of life over a 10-year period. CONCLUSIONS: An 80% rate of MABG has the potential to prevent more than 10,000 deaths annually and add >64,000 person-years of life over the course of 10 years. The use of a second arterial graft during CABG should be routine in the majority of patients undergoing CABG.

CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting.

BACKGROUND: Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES). OBJECTIVES: This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG). METHODS: We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts. RESULTS: BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001). CONCLUSIONS: Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

Multi Versus Single Arterial Coronary Bypass Graft Surgery Across the Ejection Fraction Spectrum.

BACKGROUND: Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF). METHODS: We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons. RESULTS: Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results. CONCLUSIONS: MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction.

Left atrial dissection: an almost unknown entity.

Left atrial dissection is an exceedingly rare but potentially fatal complication of cardiac surgery. It is most commonly associated with mitral valve surgery, including both replacement and repair, with a reported incidence rate of 0.16%. However, other cardiac surgical or catheter-based interventional procedures are also known as potential predisposing factors. The time of presentation from the cause of dissection varies extremely, ranging from immediate occurrence up to 20 years later. The dissection forms a large cavity between the endocardium and epicardium of the left atrium, causing obliteration of the left atrial cavity and resultant haemodynamic compromise, which almost always requires immediate surgical intervention. In contrast, left atrial dissection without haemodynamic instability can often be managed non-operatively with satisfactory outcomes. This article reviews this rare but relevant clinical entity to further elucidate the incidence, pathogenesis, clinical course, management and outcome of left atrial dissection.

Congenital coronary artery fistulae: a rare cause of heart failure in adults.

Coronary artery fistulae are uncommon, reported in 0.25% of patients undergoing coronary angiography. Two patients with congenital coronary artery fistula and coronary artery disease who presented with symptoms of exacerbated congestive heart failure out of proportion to their atherosclerotic burden were successfully treated by epicardial fistula ligation and coronary artery bypass grafting with marked improvement in functional status.

Optimal conduit for diabetic patients: propensity analysis of radial and right internal thoracic arteries.

BACKGROUND: Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revascularization of diabetic patients, we compared the outcomes for RA and RITA grafts to the circumflex coronary. METHODS: From January 1, 1995, to December 31, 2011, 908 consecutive diabetic patients underwent first-time, isolated CABG (99% on-pump), 659 with the RA and 502 with the RITA, respectively, in two affiliated hospitals. Data were prospectively collected, and late mortality was determined from the Social Security Death Index. Propensity matching, based on preoperative and operative variables, identified 202 matched pairs from each group. RESULTS: Long-term survival was similar for matched patients. Mortality, myocardial infarction, reoperation for bleeding, stroke, sepsis, and renal failure were not significantly different between groups. However, deep sternal wound infection (p<0.035) and respiratory failure (p<0.048) favored the RA group, in which the total major adverse events were significantly fewer (p=0.002). CONCLUSIONS: In diabetic patients undergoing multivessel revascularization with either RA or RITA grafts to the circumflex coronary, long-term survival is similar. However, RA patients experienced significantly fewer respiratory or sternal wound adverse events. The RA is the preferred conduit to extend to more diabetic patients the recognized survival benefit of a multiple arterial graft strategy.

Interventions for coronary artery disease (surgery vs angioplasty) in diabetic patients.

Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.

Progressive dyspnea in patient with large mediastinal mass.

Liposarcoma occurs very rarely in the mediastinum. Patients often remain asymptomatic until it grows large enough to cause direct invasion or compression of adjacent organs. We report a case of a 77-year-old male presented with dyspnea of exertion and was found to have a large mediastinal mass which was eventually diagnosed as primary mediastinal well-differentiated liposarcoma. The limited respiratory function at the initial presentation prompted phrenic nerve preserving incomplete resection rather than radical removal of the adjacent mediastinal structures. After surgical removal, the recurrence for well-differentiated mediastinal liposarcomas in the mediastinum is unknown; therefore, close follow-up is crucial.

The second best arterial graft: a propensity analysis of the radial artery versus the free right internal thoracic artery to bypass the circumflex coronary artery.

OBJECTIVE: We sought to determine if the radial artery (RA) or the free right internal thoracic artery (RITA) is the better conduit to bypass the circumflex coronary artery during coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA). METHODS: Propensity matching was performed on 2488 CABG-LITA patients from 2 affiliated centers, resulting in 528 pairs who received either a RA at one center or a free RITA at the other center to bypass the circumflex coronary artery from 1995 to 2009. RESULTS: Kaplan Meier estimated 1-, 5-, 10-, and 15-year survival rates were 99%, 95%, 85%, and 76% for RA patients, respectively, and 97%, 92%, 80%, and 71% for RITA patients, respectively (P = .060). Major adverse events (MAEs) were fewer in the RA group (7.6% vs 14.0%; P = .001) and use of the RA was a significant predictor of reduced MAEs (odds ratio [OR], 0.48; P = .002) in all patients and especially in diabetic (OR, 0.32; P = .003), older (OR, 0.40; P = .009), obese (OR, 0.15; P < .001), and chronic obstructive pulmonary disease (COPD) (OR, 0.05; P = .016) patients. However, survival was better with RA only in COPD (hazard ratio, 0.49; P = .045) and older (hazard ratio, 0.71; P = .050) patients. Overall RA patency (83.9%) was similar to RITA patency (87.4%) at a mean of 5.1 ± 3.8 years (P = .155). CONCLUSIONS: Long-term survival is similar in CABG-LITA patients using either a RA or free RITA graft to bypass the circumflex coronary artery. RA grafting has fewer MAEs, a similar patency to RITA, and improves survival in older and COPD patients. The choice of the second arterial conduit should be guided by patient profiles and surgeon preferences.

Time-varying survival benefit of radial artery versus vein grafting: a multiinstitutional analysis.

BACKGROUND: A survival benefit of radial artery use versus saphenous vein grafting in coronary artery bypass grafting (CABG) has been reported. We aimed to elucidate the relative radial artery survival benefit as a function of time after surgery from two independent CABG series. METHODS: We compared 0- to 15-year survival with radial artery versus saphenous vein grafting in isolated, nonsalvage primary CABG with left internal thoracic artery to left anterior descending from two institutions: Ohio (radial artery [n=2,361; 61 years]; saphenous vein [n=2,547; 67 years]), and New York (radial artery [n=1,970; 58 years]; saphenous vein [n=2,974; 69 years]). Separate multivariate radial artery-use propensity models based on demographic, preoperative factors, intraoperative variables, and completeness of revascularization data were computed and used to derive propensity- and sex-matched CABG cohorts (1,799 [Ohio] and 995 [New York] pairs). A three-phase (early and late) mortality model was fit to Kaplan-Meier mortality estimates and used to derive relative radial artery versus saphenous vein hazard functions. RESULTS: Radial artery use patterns and patient risk profiles differed substantially for New York and Ohio, with the New York radial artery cohort significantly younger and more male. Within-institution matched graft-type cohorts were well matched. Cumulative mortality was significantly better for radial artery at both institutions (p < 0.001 both). All mortality-time data were well described by the three-phase model, and the derived relative hazard functions were qualitatively and quantitatively similar for New York and Ohio, exhibiting maximal benefit between 0.5 and 5 years. CONCLUSIONS: Despite substantial differences in radial artery use patterns during a 15-year period, our analysis in large propensity-matched radial artery and saphenous vein cohorts yielded remarkably similar, time-varying radial artery to saphenous vein survival benefit at both institutions. These converging findings based on two independent patient series extend currently available objective evidence in support of a radial artery survival advantage in CABG.

Results of endoscopic radial artery harvesting in 1577 patients.

OBJECTIVE: We reviewed 1577 consecutive patients undergoing coronary artery bypass grafting (CABG) using endoscopic harvesting of the radial artery (RA) to define our current results. METHODS: Since 2000, we have performed endoscopic RA harvest on 1577 consecutive patients; 1476 patients had isolated CABG, and 101 patients had CABG and other procedures. The mean ± SD age was 59.4 ± 9.0 years; 80.2% were men and 40% had diabetes mellitus. All data were prospectively collected. All-cause mortality was determined using the Social Security Death Index. RESULTS: There were nine in-hospital or 30-day deaths, for an operative mortality of 0.57%: mortality was 0.34% in isolated CABG and 3.85% in CABG/combined procedures. The overall estimated Kaplan-Meier survival at 1, 5, and 10 years was 99%, 95%, and 88%. In 37 patients, the RAs were not harvested or were not used for grafting because of a positive Allen test, extensive calcification or dissection, intramural hematoma, and scarring from previous arterial lines or catheterization. During postoperative follow-up, five patients (0.32%) were treated for incisional infection, and there were no ischemic hand complications. Three patients had a perioperative myocardial infarction in the RA graft distribution, and 15 patients had a coronary artery reintervention in the RA graft distribution. Two other patients had a percutaneous coronary intervention of their RAs. The overall RA patency at 10 years was 82%. CONCLUSIONS: Endoscopic harvest of the RA is an excellent minimally invasive conduit harvesting technique with minimal morbidity.

Left atrial dissection: etiology and treatment.

BACKGROUND: Left atrial dissection (LatD) is a rare entity most commonly associated with mitral valve surgery. We have reviewed our experience with 4 patients to better define the etiology and the treatment of LatD. METHODS: From 1991 to 2012, 4 patients experienced LatD after surgery (1 of 6,302, or 0.02%, of isolated coronary artery bypass grafting patients and 3 of 1,895, or 0.16%, of mitral valve patients). Patient and perioperative data and management were reviewed. RESULTS: Two patients were women, and ages ranged from 49 to 80 years. Three patients underwent mitral procedures (two replacements with coronary artery bypass grafting and one repair) for mitral regurgitation. One patient underwent emergent isolated coronary artery bypass grafting after cardiopulmonary resuscitation for a left main dissection during percutaneous coronary intervention. Three LatDs were found during surgery, and one LatD was found 12 days after mitral repair and was successfully treated nonoperatively. The LatD was located along the posterior atrial wall originating from the atrioventricular junction in all cases and obstructed mitral valve inflow. Operative repair focused on the evacuation of hematoma, obliteration of the false lumen, and repair of the entry injury. No mortality occurred. CONCLUSIONS: Left atrial dissection is a rare complication of cardiac surgery, probably related to a contained atrioventricular separation allowing pressurized blood to separate the layers of the posterior left atrium. Prompt intraoperative diagnosis, obliterating the false cavity, and addressing the entry point are essential. In contrast, a nonoperative approach in a stable patient with a delayed LatD suggests healing of the dissection, and atrial remodeling occurs.

Improving long term outcome for diabetic patients undergoing surgical revascularization by use of the radial artery conduit: a propensity matched study.

BACKGROUND: Diabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA. METHODS: A propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010. RESULTS: We compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/- SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122]. CONCLUSION: For diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined.

Radial artery grafting in women improves 15-year survival.

OBJECTIVES: Radial artery (RA) grafting has a clear survival advantage after coronary artery bypass grafting (CABG) in studies with predominantly male populations, but the impact on women's long-term survival is unclear. We sought to determine if the reported long-term survival benefit of RA versus saphenous vein (SV) grafting in the general CABG population is valid for women. METHODS: Between 1995 and 2010, 1339 female patients were alive 30 days after primary, isolated CABG with left internal thoracic artery (LITA) and additional RA or SV conduits as needed. Patients were evaluated based on RA use: 332 patients had RA and 1007 patients had SV. Of these, 283 RA patients were matched to SV counterparts using a nonparsimonious propensity model based on 45 patient variables. RESULTS: Kaplan-Meier estimated survivals for the matched RA women at 1, 5, 10, and 15 years were 99%, 93%, 80%, and 70% versus 97%, 87%, 72%, and 58% for the SV women (log rank, P = .018). For symptomatic patients, overall RA patency was 80%, which was not different from the LITA patency rate of 84% but was superior to the SV conduits patency rate of 56% (P < .001). CONCLUSIONS: In women undergoing CABG with LITA grafting, use of an RA graft improves survival compared with use of an SV graft.

Complicated sporadic cardiac myxomas: a second recurrence and myxomatous cerebral aneurysms in one patient.

A second recurrence of an excised nonfamilial cardiac myxoma is rare. Myxomatous cerebral aneurysms as a complication of cardiac myxomas are equally rare. A unique case of a patient with a total of 4 myxomas over a 20-year interval is presented. Her most recent presentation was a second recurrence of a left atrial myxoma, a de novo right atrial myxoma, and multiple cerebral myxomatous aneurysms. The challenging reconstruction of the normal anatomy was achieved with the use of porcine extracellular matrix patches. A diagnostic cerebral angiogram was later performed, and the aneurysms will be monitored for growth and possible intervention.

Coronary artery bypass grafting using the radial artery: clinical outcomes, patency, and need for reintervention.

BACKGROUND: Radial artery (RA) grafts are an attractive second arterial conduit after the left internal thoracic artery (LITA) for coronary artery bypass graft (CABG) surgery. However, long-term outcomes and the need for subsequent reintervention have not been defined. METHODS AND RESULTS: We performed a retrospective cohort study of our single institution's 16-year experience with 1851 consecutive patients (average age, 58 years; 82% men, 36% diabetic) undergoing primary, isolated CABG with the LITA, RA, and saphenous vein as needed. Average grafts per patient were 3.8, with 2.4 arterial grafts per patient. Survival was determined using the Social Security Death Index. Grafts were nonpatent if they had a >50% stenosis, a string sign, or were occluded. Five patients (0.3%) died in hospital and 0.8% had a myocardial infarction, 1.1% a stroke, and 0.6% renal failure. Kaplan-Meier-estimated 1-, 5-, 10-, and 15-year survival was 99%, 96%, 89%, and 75%, respectively. Of the cohort, 278 symptomatic patients underwent cardiac catheterization at our institution an average of 5.0±3.8 years (range, 0.1-12 years) after CABG. Overall RA (n=420 grafts) patency was 82% and SV (n=364 grafts) patency, 47% (P<0.0001). LITA (n=287 grafts including 9 sequential grafts) patency was 85% and right internal thoracic artery (n=15 grafts) patency was 80% (P=0.6). RA patency was not different from LITA patency (P=0.3). Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively. CONCLUSIONS: RA grafting is a highly effective revascularization strategy providing excellent short and long-term outcomes with very low rates of reintervention. RA patency is similar to LITA patency and is much better than SV patency. RA grafting should be more widely utilized in patients undergoing CABG.