Effective median sternotomy closure in high-risk open heart patients.

We describe a novel surgical technique with a median sternotomy closure in high-risk open heart patients. In contrast to conventional sternal closure, in which sternal wires are passed through the intercostal space, the novel technique in sternal closure passes sternal wires transcostally or through costo-chondral joints.

Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: six-month patency rates.

OBJECTIVE: We sought to compare the 6-month angiographic patency rates of greater saphenous veins removed during coronary artery bypass grafting with the endoscopic vein harvest or open vein harvest techniques. METHODS: Two hundred patients undergoing nonemergency on-pump coronary artery bypass grafting were prospectively randomized to either endoscopic vein harvest or open vein harvest. Follow-up angiography of all vein grafts was scheduled at 6 months. Graft patency and disease grades were assigned independently by 2 interventional cardiologists. Leg wound healing was evaluated at discharge, 1 month, and 6 months for evidence of complications. RESULTS: There were 3 conversions from endoscopic vein harvest to open vein harvest because of vein factors. Leg wound complications were significantly lower in the endoscopic vein harvest group (7.4% vs 19.4%, P = .014). On multivariable analysis, endoscopic vein harvest emerged as the only factor affecting wound complications (odds ratio, 0.33). Three deaths (2 perioperative and 1 late) occurred in the endoscopic vein harvest group that were unrelated to vein graft closure. Twenty-four and 29 patients in the endoscopic vein harvest and open vein harvest cohorts, respectively, refused the follow-up 6-month angiography. Therefore a total of 144 angiograms (73 endoscopic vein harvests and 71 open vein harvests) and 336 vein grafts (166 endoscopic vein harvests and 170 open vein harvests) were available for analysis. The overall occlusion rates at 6 months were 21.7% for endoscopic vein harvest and 17.6% for open vein harvest. Additionally, there was evidence of significant disease (>50% stenosis) in 10.2% and 12.4% of endoscopic vein harvest and open vein harvest grafts, respectively. By means of ordinal hierarchic logistic regression, endoscopic vein harvest was not found to be a risk factor for vein graft occlusion or disease (odds ratio, 1.15). Significant predictors were congestive heart failure (odds ratio, 2.87), graft to the diagonal artery territory (odds ratio, 1.76), larger vein conduit size (odds ratio, 1.32), and graft flow (odds ratio, 0.90). CONCLUSION: Endoscopic vein harvest reduces leg wound complications compared with open vein harvest without compromising the 6-month patency rate. The overall patency rate depends on target and vein-related variables and patient characteristics rather than the method of vein harvesting.

Presurgical cognitive deficits in patients receiving coronary artery bypass graft surgery.

Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) can produce a higher incidence of neuropsychological complications than other types of highly invasive noncardiac vascular surgery. Cognitive complications most likely arise from either embolization or hypoxia. An alternative surgical procedure has been developed that allows CABG to be performed without stopping the heart ("off-pump" CABG, or OPCABG). This study examined the neuropsychological performance of patients undergoing OPCABG, hypothesizing that patients undergoing OPCABG would show fewer cognitive deficits than patients whose hearts were stopped. A 1-hr neuropsychological battery was administered preoperatively to 43 patients before prospective randomization to either CPB CABG or OPCABG, and again to 34 of those patients 2 to 3 months postoperatively by an examiner blind to surgical condition. Neuropsychological status did not change 2.5 months postsurgically in either OPCABG or CABG groups. However, both groups showed dramatic presurgical cognitive deficits in multiple domains, particularly verbal memory and psychomotor speed. This corroborates previous research suggesting that patients requiring CABG surgery may evidence significant presurgical cognitive deficits as a result of existing vascular disease.

Randomized trial comparing partial versus complete chordal-sparing mitral valve replacement: effects on left ventricular volume and function.

OBJECTIVE: The merits of retaining the subvalvular apparatus during mitral valve replacement for chronic mitral regurgitation have been demonstrated in numerous retrospective clinical investigations but not in a randomized study. In this report we analyzed the early and late effects of complete versus partial chordal preservation on left ventricular mechanics. METHODS: Forty-seven patients undergoing isolated surgical correction of mitral insufficiency were prospectively randomized to either total or partial chordal-sparing mitral valve replacement. Complete data from 36 patients were available for analysis. Of these individuals, 15 had preservation of the posterior leaflet only (P-MVR group), and 21 had complete preservation of all chordal structures (C-MVR group). Echocardiography was performed preoperatively, at the time of discharge, and after 1 year to determine dimensions, wall stress, left ventricular mass, and ejection function. RESULTS: End-diastolic volume decreased in both groups initially but continued to decline only in the C-MVR cohort. Similarly, although end-systolic volume decreased over time with total chordal preservation, no notable changes were observed in the P-MVR group. In the C-MVR group, end-systolic stress decreased initially but rose slightly by 1 year. In contrast, end-systolic stress remained unchanged at discharge in the P-MVR group and increased at 1 year. In terms of systolic performance, ejection fraction declined after surgical intervention with partial chordal-sparing techniques and did not improve by 1 year. Ejection fraction returned to the preoperative level after an initial decrease in the C-MVR group. Finally, left ventricular mass was reduced in the C-MVR cohort versus no change in the P-MVR group. CONCLUSION: Complete retention of the mitral subvalvular apparatus during mitral valve replacement confers a significant early advantage by reducing left ventricular chamber size and systolic afterload compared with partial chordal preservation. Furthermore, left ventricular ejection performance continues to improve over time, probably because of more favorable left ventricular remodeling.