Del Nido cardioplegia versus blood cardioplegia in coronary artery bypass grafting.

Purpose: The del Nido cardioplegia (DC) has been extensively used in congenital heart surgery for over two decades and is becoming popular in adult cardiac surgery. We evaluated the efficacy and safety of DC, compared to conventional blood cardioplegia (BC), in adult patients undergoing isolated coronary artery bypass grafting (CABG). Methods: This metachronous study included a total of 2330 consecutive patients who underwent isolated CABG. The study population was divided into two groups: BC group, consisting of 1165 patients (May 2012 through December 2015); and DC (del Nido) cardioplegia group consisting of 1165 patients (January 2016 through June 2018). Propensity matching yielded 735 well-matched pairs. The propensity-matched cohorts of BC and DC were compared in terms of myocardial function outcomes and other clinical outcomes to determine the efficacy and safety of both the cardioplegic solutions. Results: There was no difference in 30-day mortality [odds ratio (OR), 0.74; 95% confidence interval (CI), 0.16-3.35, p = 0.70]. There was a significant decrease in the DC group in the postoperative events, including re-exploration rates [OR, 0.25; 95% CI, 0.118-0.568, p < 0.001], myocardial infarction [OR, 0.282; 95% CI, 0.133-0.596, p < 0.001], left ventricular dysfunction [OR, 0.60; 95% CI, 0.396-0.916, p = 0.018], and acute kidney injury (AKI) [OR, 0.255; 95% CI, 0.156-0.418, p < 0.001]. The rate of spontaneous return to sinus rhythm was significantly higher in the DC group [OR, 5.162; 95% CI, 3.701-7.198, p < 0.001]. Cardiopulmonary bypass time (95.2 ± 29.1 min vs. 82.1 ± 28.8 min, p < 0.001) and aortic cross-clamp (ACC) time (57.3 ± 19 min vs. 48.7 ± 19.0 min, p < 0.001) were higher in the DC group, but the absolute difference in ACC time was only 8 min. There was no difference in AKI requiring renal replacement therapy [OR, 0.62; 95% CI, 0.203-1.912, p = 0.40], postoperative cerebrovascular accidents [OR, 0.398; 95% CI, 0.077-2.059, p = 0.073], and postoperative ventricular arrhythmias [OR, 0.80; 95% CI, 0.456-1.916, p = 0.47]. Conclusion: This study revealed comparable clinical outcomes and effective myocardial protection with DC, compared to BC in patients undergoing isolated CABG. In addition, DC demonstrated the ease of administration with the feasibility of single-dose administration.

Five-year outcomes of off and on-pump CABG: Insights from PROMOTE Patency Trial.

BACKGROUND: There are limited studies reporting follow-up outcome data comparing of off-pump coronary artery bypass (OPCAB) with on-pump (ONCAB) technique. The aim of the study was to report the 5-year clinical outcomes of OPCAB and ONCAB in a post hoc analysis of the PROMOTE patency trial. METHODS: From March 2016 through March 2017, a total of 321 patients undergoing coronary artery bypass grafting (CABG) were randomised to either the off-pump or the on-pump technique. Data on all-cause mortality, myocardial infarction (MI), cerebrovascular accident (CVA), repeat revascularisation and need for renal replacement therapy (RRT) were recorded. The composite and each of these individual outcomes are reported at 5-year interval. RESULTS: The mean follow-up period was 65.9 months (±3.39). A total of 275 (85.93%) patients followed up at the 5-year interval who underwent CABG by the off-pump (n = 158) and the on-pump (n = 162) technique. The all-cause mortality was 8.9% and 5.7% in ONCAB and OPCAB, respectively (hazard ratio [HR] = 0.62; 95% confidence interval [CI] 0.25-1.57, p = 0.31). The composite of all-cause mortality, non-fatal MI, non-fatal CVA, RRT and need for repeat revascularisation was comparable in both groups (7.1% vs. 11.9%, HR = 0.57; 95% CI 0.25-1.31, p = 0.18 in OPCAB and ONCAB, respectively). The rates of 5-year non-fatal MI (p = 0.2), non-fatal CVA (p = 0.36) and need for repeat revascularisation (p = 1) were similar in both groups. A sub-group analysis did not show any significant interaction or effect modification with either of the techniques. CONCLUSIONS: The 5-year clinical outcomes of OPCAB are comparable to ONCAB in low-risk patients undergoing CABG. Off-pump coronary artery bypass had no additional benefit in any subgroup.

Female gender does not have any significant impact on the early postoperative outcomes after coronary artery bypass grafting: a propensity-matched analysis.

Purpose: Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure performed in India. There are fundamental differences between males and females in the incidence and responses of the body to various diseases. These differences are noticeable, more so in conditions relating to cardiovascular health, particularly coronary artery disease (CAD). This study aims to assess the gender differences in the early postoperative outcomes following CABG. Methods: Between April 1999 through February 2018, 13,415 patients underwent isolated CABG in our practice. Propensity score matching was performed to yield 1825 well-matched pairs in each gender. These groups were compared in terms of various early postoperative outcomes. Results: There were no significant differences between females and males in terms of early postoperative composite outcomes (4.2% vs. 5.2%) (odds ratio (OR) 0.82; 95% confidence interval (CI) 0.60-1.12, p = 0.213) of 30-day mortality, non-fatal myocardial infarction (MI), non-fatal cerebrovascular accidents (CVA), and need for renal replacement therapy (RRT), 30-day mortality (0.7% vs. 0.7%) (OR 1.11; 95%CI 0.50-2.45, p = 0.796), MI (2.7% vs. 3.1%) (OR 0.93; 95%CI 0.63-1.37, p = 0.708), CVA (0.4% vs. 0.8%) (OR 0.46; 95%CI 0.19-1.14, p = 0.096), and need for RRT (0.7% vs. 0.7%) (OR 0.88; 95%CI 0.40-1.93, p = 0.753). Conclusion: Females have similar early postoperative outcomes compared to males in terms of composite outcomes of 30-day mortality, non-fatal MI, non-fatal CVA, and RRT among patients undergoing CABG. The outcomes are also similar when individually assessed. The off-pump technique has no additional benefit compared to the on-pump technique in females undergoing CABG.

Surgical management of drug-eluting stent associated coronary artery aneurysms: a case series.

Drug-eluting stents (DES) have been introduced to counter the in-stent restenosis associated with bare metal stents. However, the mechanism of action of DES results in a counter-productive effect of coronary artery aneurysm (CAA) formation. Although CAA after the implantation of drug-eluting stents (DES) is a rare occurrence with an incidence rate of up to 0.5%, they are increasingly being detected due to the progressive rise in the usage of DES for the management of coronary artery disease (CAD). Due to the rarity of this condition, evidence and guidelines regarding the management strategies for this condition are still lacking. We present a series of 5 cases of CAA, post-DES implantation, who were all successfully managed with surgical intervention.

Surgical revascularization strategies of CAD involving dual left anterior descending artery.

Dual left anterior descending artery (LAD) is not an uncommon coronary artery anomaly. Preoperative identification of this anomaly in patients with coronary artery disease is important to develop strategies to ensure complete revascularization of the LAD territory. From April 1996 through February 2022, more than 16,500 patients underwent isolated coronary artery bypass surgery (CABG) by our team. Retrospective review of the angiographic and operative records of these patients revealed 85 cases with stenosis of the dual LAD system. The incidence of dual LAD in patients undergoing CABG is 0.51%. Among the 85 patients, 59 (69.4%) had stenosis of both long and short LADs, whereas the remaining 26 (30.5%) had stenosis of either of the LADs. Among the 59 patients who had stenosis of both the LADs, 26 (44.1%) received a left internal thoracic artery (LITA) sequential graft to bypass both the LADs and two received a LITA-LITA baby-Y graft. And in 31 (52.5%) patients, the longer LAD was revascularized with LITA and the other LAD with saphenous vein graft.

Trends of re-operative coronary artery bypass grafting: A two-decade experience.

BACKGROUND: The prevalence of redo coronary artery bypass grafting has markedly changed over the last two decades. We aim to assess the trends of redo coronary artery bypass grafting and clinical outcomes of redo coronary artery bypass grafting over two different periods. METHODS: This is a retrospective, metachronous, observational study of patients who underwent redo coronary artery bypass grafting between January 1998 through December 2004 and January 2005 through September 2021 who were categorized into group 1 and group 2, respectively. The trends in the prevalence of redo coronary artery bypass grafting, and 30-day outcomes were analyzed. RESULTS: A total of 261 patients underwent a redo coronary artery bypass grafting. Group 1 and group 2 included 114 and 147 patients, respectively. 62.59% of group 2 patients underwent off-pump coronary artery bypass grafting compared to 6.14% in group 1 (p < 0.01). The patients undergoing redo coronary artery bypass grafting in group 2 were significantly older (60.65 ± 7.78 years vs. 50.99 ± 7.66 years, p < 0.001) and were more likely to be hypertensive (49.66% vs. 29.82%, p < 0.001). There was no significant difference in the proportion of diabetes (p = 0.82), smoking (p = 0.24), dyslipidemia (p = 0.64), and preoperative myocardial infarction (p = 0.14). The proportion of patients who presented post-PCI was significantly higher in group 2 (27.89% vs. 10.53%, p < 0.001). There was also a shift in the usage of grafts from the left internal thoracic artery to the saphenous vein graft (p < 0.001). CONCLUSION: The annual rate of redo coronary artery bypass grafting was declining but has now reached a plateau. The current outcomes of patients undergoing redo coronary artery bypass grafting are comparable to that of the earlier times despite a higher co-morbidity burden in patients of recent times.

Predictors of mortality and morbidity in total anomalous pulmonary venous connection with biventricular physiology: A 10-year Indian single centre experience of 492 patients.

Background: Surgical correction of total anomalous pulmonary venous connection (TAPVC) remains associated with significant mortality despite advances in intra-operative and postoperative management. We retrospectively analyzed 492 consecutive TAPVC patients with biventricular physiology, who were operated at our centre, with regard to predictors of mortality, morbidity, and intermediate-term outcomes. Materials and Methods: A total of 492 TAPVC patients with biventricular physiology were operated at our centre from August 2009 to November 2019. Their medical records were reviewed and were followed up during March-April 2020 for any symptoms of cardiac disease. Results: Of 492, 302 (61.38%) were healthy at follow-up, 29 (5.89%) had postoperative mortality, 23 (4.67%) had mortality during the follow-up period, and 138 (28.05%) were lost to follow up. Age <1 month and weight <2.5 kg were associated with higher mortality with odds ratios (OR) of 6.37 and 5.56, respectively. There was no difference in mortality in different types of TAPVC. Obstructed TAPVC was associated with higher mortality with OR of 3.05. Acute kidney injury requiring peritoneal dialysis and sepsis were associated with higher mortality with ORs of 10.17 and 3.29, respectively. All follow-up mortality occurred in <1 year from the index operation. Anastomotic gradients were significantly higher in patients who died. Conclusions: Although peri-operative TAPVC mortality has reduced, mortality on follow-up continues to occur and is partly due to the obstruction of pulmonary venous pathway. Meticulous follow-up holds the key in further reducing the mortality. Larger studies are needed for the identification of risk factors for pulmonary venous obstruction and its preventive strategies.

Graft patency at 3 months after off- and on-pump coronary bypass surgery: a randomized trial.

PURPOSE: Coronary artery bypass grafting (CABG) is performed either with the aid of cardiopulmonary bypass (on-pump) or without cardiopulmonary bypass (off-pump). There is a scarcity of angiographic data to support the non-inferiority of off-pump technique to on-pump technique. The objective of this study is to ascertain the non-inferiority of off-pump CABG when compared to on-pump CABG in terms of angiographically assessed graft patency at 3 months. METHODS: A total of 320 patients with multivessel coronary artery disease were enrolled in a multicenter prospective randomized trial either to on-pump CABG (n = 162) or off-pump CABG (n = 158) between March 2016 through March 2017. Graft patency was evaluated by using either multidetector computerized tomographic angiography or conventional coronary angiography at 3 months. The major adverse cardiac and cardiovascular events (MACCE) were also analyzed at 3 months. RESULTS: The median number of grafts per patient in off-pump was 3.00 (Q1:3.00 and Q3:4.00) vs on-pump 4.00 (Q1:3.00 to Q3:4.00), and the mean number of grafts per patient was lower in the off-pump CABG at 3.45 ± 0.75 vs 3.64 ± 0.70 in the on-pump CABG (p = 0.01). There was no significant difference in mortality at 3 months between the off-pump (0.63%) and on-pump groups (1.85%) with p value of 0.62. The cumulative combined MACCE showed significant difference between off-pump group (0.63%) and on-pump group (5.55%), p = 0.01. Follow-up angiograms were done in 239 (75%) patients with 120 off-pump and 119 in the on-pump group. The analysis was also done regarding graft patency in a graded manner-when analysis of A (excellent) grafts vs B (stenosed) grafts and O (occluded) grafts were made, there was no statistically significant difference in overall graft patency at 3 months between on-pump [376 /429 grafts (87.6%)] and off-pump [366 /420 grafts (87.1%)] groups (p = 0.82). The patency rates were similar among bypass conduits (left internal thoracic artery (ITA) in off-pump (91.4%) vs on-pump (92.9%) p = 0.66, right ITA in off-pump (82.1%) vs on-pump (81.8%) p = 0.97, radial artery in off-pump (84.4%) vs on-pump (82.6%) p = 0.81; saphenous vein in off-pump (85.8%) vs on-pump (86.3%), p = 0.86 and among 3 coronary territories. CONCLUSIONS: Off-pump CABG is non-inferior to on-pump CABG in terms of overall graft patency at 3 months and was associated with a fewer combined cumulative MACCE compared to on-pump CABG.

One-year outcomes of off- and on-pump coronary artery bypass grafting: PROMOTE patency trial.

PURPOSE: Earlier we reported 3-month graft patency and clinical outcomes of prospective randomized comparison of off-pump and on-pump multivessel coronary artery bypass surgery to evaluate outcomes and graft patency (PROMOTE patency) trial. We now report major adverse cardiac and cerebrovascular events (MACCE) at 1 year of patients who underwent coronary artery bypass grafting (CABG) using either off-pump technique or on-pump technique. METHODS: The PROMOTE patency trial is a two-arm, prospective, randomized, multicentre trial, and enrolled 320 patients with multivessel coronary artery disease from March 2016 through March 2017 at 6 centres and were randomly assigned to undergo either off-pump CABG (OPCAB) (n = 158 patients) or on-pump CABG (n = 162 patients). The outcomes at 1 year were assessed. RESULTS: One mortality (0.64%) occurred in off-pump group (at 30 days) and 4 (2.48%) in on-pump group (1 at 30 days, 2 at 3 months, and 1 at 1 year) (p = 0.37). There was no difference between off-pump and on-pump groups in the outcomes of nonfatal myocardial infarction (1 in off-pump and 2 in on-pump group, p = 1.00) and cerebrovascular accident (none in off-pump and 2 in on-pump group, p = 0.49). Repeat revascularization was done in one patient in each group (p = 1.00). CONCLUSION: There was no significant difference in the incidence of MACCE between off-pump and on-pump CABG group at 1 year.

Impact of occult renal disease on the outcomes of off-pump and on-pump coronary artery bypass grafting.

PURPOSE: Occult renal disease (ORD) is a clinical condition in which glomerular filtration rate (GFR) is less than 60 ml/min/1.73 m2, while serum creatinine is ≤ 1.3 mg/dl. The aim of the study was to compare the incidence of postoperative stage I acute kidney injury (AKI) according to Acute Kidney Injury Network (AKIN) classification in patients with ORD undergoing either off-pump or on-pump coronary artery bypass grafting. METHODS: A single center prospective randomized study was conducted from March 2011 through January 2014. A total of 120 coronary artery disease (CAD) patients with ORD undergoing coronary artery bypass grafting (CABG) were randomized to either off-pump (group1, n = 62) or on-pump (group2, n = 58) CABG in 1:1 ratio by computer-generated random number table. The GFR and serum creatinine levels were measured preoperatively and postoperatively on day 1 and day 5. The primary outcome (postoperative AKI (stage I)) and secondary outcomes (AKI (stage III) requiring renal replacement therapy (RRT) death, myocardial infarction (MI), cerebrovascular accident, atrial fibrillation (AF), and re-exploration for bleeding) at 30 days were analyzed between the groups. RESULTS: There is no significant difference in baseline characteristics of patients between off-pump and on-pump group. The incidence of postoperative AKI (stage I) was similar between on-pump (20.69%) and off-pump (16.13%) groups (p = 0.51). There was no significant difference in mortality (p = 0.33), postoperative MI (p = 0.34), cerebrovascular accident (p = 1.00), re-exploration (p = 0.96), and AF (p = 0.50). The number of patients of stage III AKI requiring RRT was higher in the off-pump group (3 patients, 4.8%) and none in the on-pump group (p = 0.08). CONCLUSIONS: This study demonstrated that on-pump CABG is associated with significantly lower GFR and significantly higher serum creatinine on postoperative day 1 which return to baseline by postoperative day 5. In patients with ORD undergoing CABG, the incidence of postoperative AKI and major adverse cardiac and cerebrovascular events were similar between off-pump or on-pump CABG patients.

Early hemodynamic performance of the Trifecta™ surgical bioprosthesis aortic valve in Indian patient population: 12 month outcomes of the EVEREST post-market study.

BACKGROUND: Indian patients undergoing surgical aortic valve replacement (SAVR) differ from western populations with respect to aortic annulus size and valve disease morphology. The purpose of this post-market, non-randomized observational study was to evaluate the early hemodynamic performance of the Trifecta™ bioprosthesis (Abbott, previously St. Jude Medical, Minneapolis, US) in an Indian patient population. METHODS: From January 2014 to September 2015, 100 patients (mean age 64.4 ± 7.1 years, 62% male) undergoing SAVR for valve disease (68% stenosis, 7% insufficiency, 25% mixed pathology) were enrolled across 10 centers in India. Patients implanted with a 19-27 mm Trifecta™ valve were eligible to participate and were prospectively followed for 12-months post-implantation. Echocardiographic hemodynamic performance was evaluated at pre-implant, pre-discharge and at 12-months by an independent core laboratory. Adverse events were adjudicated by the study sponsor. Functional status at 12-months was assessed according to NYHA classification. Continuous data was summarized using descriptive statistics (mean &standard deviation,) and categorical data was summarized using frequencies and percentages. RESULT: Ninety patients (mean age 64.5, 62.2% male) completed the 12-month follow up. Significant improvements in hemodynamic valve performance were reported in 81 patients with available echocardiographic data at 12 months. Compared to baseline at 12-month follow up visit, mean effective orifice area increased from 0.75cm2 to 1.61cm2 (p < 0.0001), mean pressure gradient reduced to 10.42 mmHg from 51.47 mmHg (p < 0.0001), cardiac output increased from 4.46 l/min to 4.85 l/min (P 0.9254). Compared to baseline, functional status improved by ≥1 NYHA class in 75% of patients at 12 months (95% Clopper-Pearson (Exact) confidence limit [64.6%, 83.6%]). No instances of early mortality (< 30 days from index procedure) or structural valve dysfunction were reported. CONCLUSION: In an Indian patient population, implantation of the Trifecta™ bioprosthesis is shown to be safe and associated with favorable early hemodynamic performance and improved functional status at 12 months. TRIAL REGISTRATION: The clinical study has been registered under Clinical Trial Registry-India ( http://www.ctri.nic.in ) and registration number is CTRI/2014/02/004434 registered on 25 February 2014 retrospectively registered.

Unique pattern of late gadolinium enhancement on cardiac magnetic resonance imaging in Duchenne muscular dystrophy.

Cardiomyopathy is an important cause of morbidity and mortality in patients with Duchenne muscular dystrophy (DMD). Early recognition of myocardial involvement and initiation of therapy are important for improved outcomes. Cardiac magnetic resonance imaging (CMR) is a sensitive tool in early detection of myocardial fibrosis in these children.

Internal thoracic artery: anatomical and biological characteristics revisited.

The left internal thoracic artery has become the conduit of choice for coronary artery bypass grafting, due to its superior patency rates at 10 or more years with little or no evidence of atherosclerotic changes. Recent evidence indicates that a second internal thoracic artery graft provides improved results relative to overall survival and major cardiac and cerebrovascular event-free survival, and reduces the need for repeat revascularization. However, the routine use of bilateral internal thoracic arteries is limited due to a perceived higher incidence of deep sternal wound infection. The surgical anatomy, collateral blood supply to the sternum, and biological characteristics of internal thoracic artery conduits are reviewed.

Reduction of sternal wound infections in diabetic patients undergoing off-pump coronary artery bypass surgery and using modified pedicle bilateral internal thoracic artery harvest technique.

OBJECTIVE: We compared sternal wound infections between diabetic patients undergoing off-pump coronary artery bypass surgery using bilateral internal thoracic artery grafting or single internal thoracic artery grafting and nondiabetic patients receiving bilateral internal thoracic artery or single internal thoracic artery grafting using a modified pedicled harvest technique of internal thoracic artery. METHODS: This retrospective study was conducted to analyze the data from 3072 patients who underwent primary coronary artery bypass surgery using an off-pump technique from August 2004 to October 2010. Of the 1211 diabetic patients, 181 received bilateral internal thoracic artery grafts (group 1) and 1030 received single internal thoracic artery grafts (group 2). Of the 1861 nondiabetic patients, 161 received bilateral internal thoracic artery grafts (group 3) and 1700 received single internal thoracic artery grafts (group 4). The incidence of postoperative sternal wound infections in diabetic patients who received bilateral internal thoracic artery grafting was compared with the incidence in other groups (group 2, 3, and 4). A modified technique of pedicled harvesting of the internal thoracic artery was done in patients receiving bilateral internal thoracic artery grafting, and a standard pedicled harvest was used in patients receiving single internal thoracic artery grafts. RESULTS: No significant differences were present in the preoperative variables among the groups. The observed rate of superficial sternal wound infections in groups 1, 2, 3, and 4 was 1.1% (2 patients), 1.65% (17 patients), 1.86% (3 patients), and 1.65% (28 patients), respectively (P=.9941). Deep sternal infections were observed in 1 (0.55%), 5 (0.48%), 1 (0.62%), and 14 patients (0.82%) in groups 1 through 4, respectively (P=.8380). Multivariate analysis showed that bilateral internal thoracic artery harvesting (P=.889), diabetes mellitus (P=.96), and patient age were not predictors of sternal wound infection. CONCLUSIONS: The results of the present study show that there is no increase in the incidence of sternal wound infections in diabetic patients undergoing coronary artery bypass surgery with bilateral internal thoracic artery grafting by using a modified pedicle bilateral internal thoracic artery harvesting technique with sparing of the communicating bifurcation of internal thoracic artery to the chest wall and preservation of pericardiacophrenic artery branch.

Impact of preoperative renal dysfunction on outcomes of off-pump coronary artery bypass grafting.

BACKGROUND: This study assessed whether preoperative renal insufficiency predisposes patients undergoing off-pump coronary artery revascularization to postoperative dialysis. METHODS: From August 2004 through June 2009, 2,275 patients undergoing off-pump coronary artery bypass were categorized into five groups (stages) by glomerular filtration rate (GFR). Of these, 1,855 patients had renal insufficiency: stage 2: 1,406; stage 3: 428; stage 4: 21, and 414 had normal renal function, stage 1. Excluded were 6 patients with end-stage renal disease (stage 5). Preoperative variables and postoperative outcomes were compared among groups. RESULTS: Preoperative patient characteristics were similar; however, patients with normal renal function were younger (p = 0.001). Serum creatinine rose significantly above baseline on the first postoperative day in the renal insufficiency groups (p = 0.001). The GFR groups had similar inotrope use, reexploration rate, duration of postoperative mechanical ventilation, postoperative stroke, wound infection, and mortality rate. Stage 4 patients had a higher incidence of postoperative myocardial infarction (p = 0.002). Stage 3 and 4 patients had an increased need for postoperative dialysis vs stage 1 patients (p = 0.002). CONCLUSIONS: Nonparametric contingency analysis showed patients with low preoperative GFR (stage 3 and 4, p < 0.0001) and a history of smoking (p = 0.04) were at increased risk for postoperative dialysis. Patients who required postoperative inotropic support tended toward requiring postoperative dialysis (p = 0.06). Low preoperative ejection fraction (p = 0.83), class III or IV angina (p = 0.069), and postoperative blood transfusions were not associated with the need for postoperative dialysis in patients undergoing off-pump revascularization.

Outcomes of mitral valve repair for chronic ischemic mitral regurgitation.

Mitral regurgitation is a frequent complication of ischemic heart disease. A retrospective study was performed on 127 patients with significant ischemic mitral regurgitation (regurgitant jet area > or =6.0 cm2 and/or vena contracta width > or =0.70 cm) who underwent elective mitral valve repair between January 2001 and October 2007. Concomitant myocardial revascularization was carried out in all except one patient, and left ventricular restoration in 8. All patients had ring annuloplasty, with release of posterior mitral leaflet tethering in 21, leaflet resection in 7, chordal transfer in 3, and chordal shortening in 2. There were 4 (3.1%) hospital deaths. Two patients underwent successful mitral valve replacement for repair failure in the immediate postoperative period, and one had an unsuccessful valve replacement at 3 months. During a mean follow-up of 19.65 +/- 13.21 months in 121 patients, 111 had trivial or no residual regurgitation, and 10 had mild regurgitation. Mitral valve repair for chronic ischemic mitral regurgitation is a reproducible technique with satisfactory early and mid-term outcomes and freedom from valve-related complications.

Off-pump coronary revascularization for left main coronary artery stenosis.

Experience of on- and off-pump coronary artery bypass in 379 patients with significant left main coronary artery stenosis was retrospectively reviewed. Beating-heart operations were performed on 219 patients between January 2001 and October 2007. Their results were compared with 160 who underwent revascularization under cardiopulmonary bypass during the same period. All patients had multivessel grafting via a median sternotomy. Both groups were comparable demographically. Off-pump patients received significantly fewer grafts per patient (3.21 +/- 0.86 vs 3.74 +/- 0.82). The use of moderate or high doses of inotropics (> 5 microg kg(-1) min(-1)) was more frequent in the on-pump group (44% vs 26%). Postoperative blood transfusion requirement was lower in off-pump patients, and fewer of them experienced worsening of preexisting renal insufficiency. There were 2 operative deaths in the on-pump group and 1 in the off-pump group. The off-pump procedure is safe and effective in patients with left main coronary artery disease.

Correction of anomalous drainage of right superior vena cava to left atrium.

A 2-year-old boy with cyanosis was found to have normal situs and looping with anomalous drainage of a right-sided superior vena cava to the left atrium, and intact interatrial septum in association with anomalous drainage of the left pulmonary veins to the right superior vena cava. He underwent successful surgical repair of this rare congenital malformation.