Quality of life outcomes in tracheobronchomalacia surgery.

Tracheobronchomalacia (TBM) is an obstructive airway disease characterized by laxity and redundancy of the posterior membrane of the main airways leading to dynamic airway collapse during exhalation. The gold standard for diagnosis is dynamic computed tomography (DCT) scan and dynamic flexible bronchoscopy (DFB). Patients with complete or near-complete collapse (>90% reduction in cross-sectional area) of the airway are possible candidates for surgical management. Central airway stabilization by tracheobronchoplasty (TBP) effectively corrects malacic airways and has demonstrated significant improvement in objective functional measures, which is often but not uniformly accompanied by equal improvement in health-related quality of life (HRQOL) metrics. This article reviews HRQOL instruments used to report outcomes after TBM surgery.

Anti-interferon-α receptor 1 antibodies attenuate inflammation and organ injury following hemorrhagic shock.

BACKGROUND: Hemorrhagic shock (HS) is a life-threatening condition resulting from rapid and significant loss of intravascular volume, leading to hemodynamic instability and death. Inflammation contributes to the multiple organ injury in HS. Type I interferons (IFNs), such as IFN-α and IFN-ß, are a family of cytokines that regulate the inflammatory response through binding to IFN-α receptor (IFNAR) which consists of IFNAR1 and IFNAR2 chains. We hypothesized that type I IFNs provoke inflammation and worsen organ injury in HS. METHODS: Male C57BL/6 mice (20-25 g) underwent hemorrhage by controlled bleeding via the femoral artery to maintain a mean arterial pressure of 27 ± 2.5 mm Hg for 90 minutes, followed by resuscitation for 30 minutes with two times shed blood volume of Ringer's lactate solution containing 1 mg/kg body weight of anti-IFNAR1 antibody (Ab) or control isotype-matched IgG (IgG). Blood and tissue samples were collected at 20 hours after the resuscitation for various analyses. RESULTS: The expression of IFN-α and IFN-ß mRNAs was significantly elevated in lungs and liver of the mice after HS. The IFNAR1-Ab treatment significantly decreased serum levels of organ injury markers lactate dehydrogenase and aspartate aminotransferase, as well as improved the integrity of lung and liver morphology, compared to the IgG control. The protein levels of proinflammatory cytokines TNF-α and IL-6, and mRNA expression of proinflammatory chemokines monocyte chemoattractant protein (MCP)-1, MCP-2, macrophage inflammatory protein 2 (MIP-2), and keratinocyte cytokine (KC) in the lungs of the HS mice were significantly decreased after treated with IFNAR1-Ab. Moreover, the myeloperoxidase activity and number of apoptotic cells in the lungs of HS mice treated with IFNAR1-Ab were decreased in comparison to the IgG control. CONCLUSION: Administration of IFNAR1-Ab reduces inflammation and tissue injury. Thus, type I IFN signaling may be a potential therapeutic target for mitigating organ dysfunction in patients suffering from HS. STUDY TYPE: Translational animal model.

Minimally Invasive coronary surgery compared to STernotomy coronary artery bypass grafting: The MIST trial.

RATIONALE: Minimally invasive cardiac surgery has emerged as a safe alternative to standard cardiac surgery. Minimally invasive coronary surgery (MICS CABG) was developed to allow adequate exposure and complete revascularization in CABG from a small thoracotomy incision without cardiopulmonary bypass. Multiple studies have reported significant shorter length of hospital stay and earlier postoperative physical recovery for MICS CABG patients when compared to sternotomy CABG patients. However, there have been no convincing clinical trials that demonstrate improvement in post-operative quality of life for patients who undergo MICS CABG. STUDY DESIGN: The Minimally Invasive Coronary Surgery compared to Sternotomy Coronary Artery Bypass Grafting (MIST) trial is a multi-centered, prospective randomized controlled trial that compares the quality of life and recovery in the early post-operative period between patients undergoing MICS CABG versus patients undergoing sternotomy CABG. Patients will be randomized either to the MICS CABG group or the sternotomy CABG group, and the target enrollment is 88 patients per group. The primary outcome is quality of life assessment performed by SF-36 questionnaire at 1 month. CONCLUSION: The MIST trial is the first prospective study that compares the quality of life between MICS CABG and sternotomy CABG patients. The results of this trial may enhance the procedural desirability of MICS CABG by patients and provide an incentive for surgeons and institutions to increase the availability of MICS CABG in suitable patients.

Cold-inducible RNA-binding protein-derived peptide C23 attenuates inflammation and tissue injury in a murine model of intestinal ischemia-reperfusion.

BACKGROUND: Cold-inducible RNA-binding protein is a novel damage-associated molecular pattern that causes inflammation. C23, a short peptide derived from cold-inducible RNA-binding protein, has been found to have efficacy in blocking cold-inducible RNA-binding protein's activity. We hypothesized that C23 reduces inflammation and tissue injury induced by intestinal ischemia-reperfusion. METHODS: Male C57BL/6 mice were subjected to 60 minutes of intestinal ischemia by clamping the superior mesenteric artery. Immediately after reperfusion, either normal saline (vehicle) or C23 peptide (8 mg/kg body weight) was injected intraperitoneally. Four hours after reperfusion, blood, intestinal, and lung tissues were collected for analysis of inflammatory and tissue injury parameters. RESULTS: Cold-inducible RNA-binding protein levels in the intestinal tissues were significantly increased following intestinal ischemia-reperfusion. Histologic examination of the intestine revealed a significant reduction in injury score in the C23 group by 48% as compared with the vehicles after intestinal ischemia-reperfusion. The serum levels of lactate dehydrogenase and aspartate aminotransferase were increased in animals that underwent vehicle-treated intestinal ischemia-reperfusion, whereas C23-treated animals exhibited significant reductions by 48% and 53%, respectively. The serum and intestinal tissue levels of tumor necrosis factor α were elevated in vehicle-treated intestinal ischemia-reperfusion mice but decreased by 72% and 69%, respectively, in C23-treated mice. Interleukin-6 mRNA levels in the lungs were reduced by 86% in the C23-treated group in comparison to the vehicle-treated group after intestinal ischemia-reperfusion. Expression of macrophage inflammatory protein 2 and level of myeloperoxidase activity in the lungs were dramatically increased after intestinal ischemia-reperfusion and significantly reduced by 91% and 25%, respectively, in the C23-treated group. CONCLUSION: C23 has potential to be developed into a possible therapy for reperfusion injury after mesenteric ischemia and reperfusion.

Improving the Power of the American Society of Anesthesiology Classification System to Risk Stratify Vascular Surgery Patients Based on National Surgical Quality Improvement Project-Defined Functional Status.

BACKGROUND: Recently published reports have shown that the American Society of Anesthesiology (ASA) classification system has limited applicability in vascular surgery patients. Most patients undergoing vascular procedures are designated as ASA class III, limiting discrimination in preoperative risk assessment. The 2006 National Surgical Quality Improvement Project (NSQIP), containing over 170,000 surgical cases, demonstrated that functional status is an important predictor of mortality. We propose that dividing ASA class III into 2 subgroups, based on NSQIP-defined functional status, improves the predictive value of the ASA scheme. METHODS: The 2006 NSQIP database was queried for ASA class III patients undergoing vascular surgery procedures. Patients were divided into groups IIIA and IIIB based on independent or dependent (partial or complete) functional status, respectively. Difference in 30-day survival between subgroups was evaluated using Kaplan-Meier and logistic regression analyses. Differences in postoperative morbidity and length of stay were compared using the unpaired t-test. RESULTS: ASA class III patients having undergone vascular surgery procedures numbered 11,555 (68%). Of those 9,913 (85.7%) patients were independent (IIIA), and 1,642 (14.3%) were dependent (IIIB). Mean 30-day mortality was 1.3% in subgroup IIIA, and 6.5% in IIIB (logrank P < 0.001, χ2, 137.8). Mean lengths of stay between subgroups IIIA and IIIB were 5.4 and 13.2 days (P < 0.001). The risk of NSQIP-defined postoperative complications was 0.16 in IIIA and 0.32 in IIIB (P < 0.001). CONCLUSIONS: A 5-fold difference in mortality was observed between patients who were functionally independent and dependent. A significant increase in length of stay and incidence of postoperative complications was also observed in subgroup IIIB. Subdividing ASA class III vascular surgery patients markedly improves the value of the ASA classification system. Given the "high-risk" nature of patients with vascular disease, the addition of functional status to the preoperative assessment will assist in predicting outcomes in this patient population.

Evolution of Minimally Invasive Coronary Artery Bypass Grafting: Learning Curve.

OBJECTIVE: Minimally invasive coronary surgery approach for coronary artery bypass grafting is a safe and reproducible procedure for multivessel revascularization. This study reviewed a single surgeon's experience with minimally invasive coronary surgery coronary artery bypass grafting, including operative time, number of bypasses, and conversion to sternotomy. METHODS: A prospective database of consecutive minimally invasive coronary surgery coronary artery bypass grafting procedures from 2005 to 2013 was reviewed. A small anterolateral left thoracotomy allowed left internal mammary artery harvest, proximal anastomoses on the ascending aorta, and distal coronary anastomoses. Early cases were compared with the later cases, focusing on grafting strategies that led to a standardized approach with Propensity Score Matching analysis. RESULTS: Seven hundred consecutive cases were divided into early (1-200) and late (201-700) groups. In the late group, the number of triple-vessel disease patients trended higher (50% vs. 57%, P = 0.0674) and the number of bypasses increased (2.3 ± 0.8 vs. 2.7 ± 1.0, P < 0.0001). Conversion to sternotomy significantly decreased between the groups (6% vs. 0.6%, P < 0.0001). There was no difference in rate of postoperative complications between the groups except for prolonged intubation (10% vs. 5%, P = 0.0236) and shortened length of stay (5.9 ± 6.7 vs. 5.5 ± 6.0, P = 0.0268). Propensity score matching analysis (n = 177) was significant for total bypass performed and time per bypass (P < 0.05). The late group was further divided into subgroups of one hundred each (subgroup 1 through 5). Operative times differed significantly (subgroup 1: 249 ± 71.2, subgroup 2: 259 ± 85.8, subgroup 3: 244 ± 71.0, subgroup 4: 270 ± 58.4, and subgroup 5: 246 ± 47.9, P < 0.005). CONCLUSIONS: As experience with minimally invasive coronary surgery coronary artery bypass grafting increased, the ideal sequence of steps to optimize surgical outcome was defined. The number of bypassed vessels increased and the operative time and conversion to sternotomy decreased.

The Protective Effect of A Short Peptide Derived From Cold-Inducible RNA-Binding Protein in Renal Ischemia-Reperfusion Injury.

Extracellular cold-inducible RNA-binding protein (CIRP) functions as damage-associated molecular pattern and has been demonstrated to be responsible in part for the damage occurring after renal ischemia-reperfusion (I/R). A short peptide derived from CIRP, named C23, binds to myeloid differentiation factor 2, a Toll-like receptor 4 coreceptor. We hypothesize that C23 reduces renal ischemia-reperfusion (RIR) injury by blocking CIRP. We observed that pretreatment with C23 significantly decreased the levels of recombinant mouse CIRP-induced tumor necrosis factor-α (TNF-α) in a dose-dependent fashion in cultured macrophages. C57BL/6 mice were subjected to bilateral renal pedicle clamps for 35 min to induce ischemia, followed by reperfusion for 24 h and harvest of blood and renal tissue. C23 peptide (8 mg/kg) or vehicle was injected intraperitoneally at the beginning of reperfusion. Plasma TNF-α, interleukin 1 beta (IL-1ß), and IL-6 levels were decreased in C23-treated RIR mice as compared with vehicle-treated mice by 74%, 85%, and 68%, respectively. Expressions of TNF-α and keratinocyte chemoattractant in the kidneys from C23-treated mice were decreased by 55% and 60%, respectively. Expression of kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin in the kidney of C23-treated mice were significantly reduced by 46% and 55%, respectively. Renal tissue histological assessments revealed significant reduction in damage score by 44% in C23-treated mice. Finally, a survival study revealed a significant survival advantage with a 70% survival rate in C23 group vs. 37% in vehicle group. Thus, C23 has potential as a novel therapy for the patients suffering from I/R-induced renal injury.

Deficiency in cold-inducible RNA-binding protein attenuates acute respiratory distress syndrome induced by intestinal ischemia-reperfusion.

BACKGROUND: Intestinal ischemia-reperfusion can occur in shock and mesenteric occlusive diseases, causing significant morbidity and mortality. Aside from local injury, intestinal ischemia-reperfusion can result in remote organ damage, particularly in the lungs. Cold-inducible RNA-binding protein (CIRP) was identified as a novel inflammatory mediator. We hypothesized that a deficiency in CIRP would protect the lungs during intestinal ischemia-reperfusion injury. METHODS: Intestinal ischemia was induced in adult male C57BL/6 wild-type and CIRP knock-out (CIRP-/-) mice via clamping of the superior mesenteric artery for 60 minutes. Reperfusion was allowed for 4 hours or 20 hours, and blood, gut, and lung tissues were harvested for various analyses. RESULTS: After intestinal ischemia-reperfusion, the elevated levels of serum lactate dehydrogenase and inflammatory cytokine interleukin-6 were reduced by 68% and 98%, respectively, at 20 hours after ischemia-reperfusion in CIRP-/- mice compared with the wild-type mice. In the gut, mRNA levels of inflammatory cytokine interleukin-6 were reduced by 67% at 4 hours after ischemia-reperfusion in CIRP-/- mice. In the lungs, inflammatory cytokine interleukin-6 protein and myeloperoxidase activity were reduced by 78% and 26% at 20 hours and 4 hours after ischemia-reperfusion, respectively, in CIRP-/- mice. Finally, the elevated lung caspase-3 was significantly decreased by 55%, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling-positive cells decreased by 91%, and lung injury score decreased by 37% in CIRP-/- mice at 20 hours after ischemia-reperfusion. CONCLUSION: Increased levels of proinflammatory cytokines, myeloperoxidase, and apoptosis are the hallmarks of acute respiratory distress syndrome. We noticed after intestinal ischemia-reperfusion the proinflammatory milieu in lungs was elevated significantly, while the CIRP-/- mice had significantly decreased levels of proinflammatory cytokine, myeloperoxidase, and apoptotic cells leading to decreased lung injury. These findings strongly established a causal link between CIRP and acute respiratory distress syndrome during intestinal ischemia-reperfusion injuries. Targeting CIRP may therefore be beneficial for treatment of intestinal ischemia-reperfusion-associated acute respiratory distress syndrome acute respiratory distress syndrome.

Cost Analysis of Physician Assistant Home Visit Program to Reduce Readmissions After Cardiac Surgery.

BACKGROUND: A physician assistant home care (PAHC) program providing house calls was initiated to reduce hospital readmissions after adult cardiac surgery. The purpose of our study was to compare 30-day PAHC and pre-PAHC readmission rate, length of stay, and cost. METHODS: Patients who underwent adult cardiac surgery in the 48 months from September 2008 through August 2012 were retrospectively reviewed using pre-PAHC patients as the control group. Readmission rate, length of stay, and health care cost, as measured by hospital billing, were compared between groups matched with propensity score. RESULTS: Of the 1,185 patients who were discharged directly home, 155 (13%) were readmitted. Total readmissions for the control group (n = 648) was 101 patients (16%) compared with the PAHC group (n = 537) total readmissions of 54 (10%), a 38% reduction in the rate of readmission (p = 0.0049). Propensity score matched groups showed a rate reduction of 41% with 17% (62 of 363) for the control compared with 10% (37 of 363) for the PAHC group (p = 0.0061). The average hospital bill per readmission was $39,100 for the control group and $56,600 for the PAHC group (p = 0.0547). The cost of providing home visits was $25,300 for 363 propensity score matched patients. CONCLUSIONS: The PAHC program reduced the 30-day readmission rate by 41% for propensity score matched patients. Analysis demonstrated a savings of $977,500 at a cost of $25,300 over 2 years, or $39 in health care saved, in terms of hospital billing, for every $1 spent. Therefore, a home visit by a cardiac surgical physician assistant is a cost-effective strategy to reduce readmissions after cardiac surgery.

Long-term Outcome after Percutaneous Coronary Intervention Compared with Minimally Invasive Coronary Artery Bypass Surgery in the Elderly.

BACKGROUND: Elderly patients with unstable coronary artery disease (CAD) have better outcomes with coronary revascularization than conservative treatment. With the improvement in percutaneous coronary intervention (PCI) techniques using drug eluting-stents, this became an attractive option in elderly. Minimally invasive coronary artery bypass grafting (MICS-CABG) is a safe and effective alternative to conventional CABG. We aimed to explore the long-term outcomes after PCI vs MICS-CABG in ≥75 year-old patients with severe CAD. METHODS: A total of 1454 elderly patients (≥75 year-old patients) underwent coronary artery revascularization between January 2005 and December 2009. Patients were selected in the study if they have one of the Class-I indications for CABG. Groups were divided according to the type of procedure, PCI or MICS-CABG, and 5 year follow-up. RESULTS: Among 175 elderly patients, 109 underwent PCI and 66 had MICS-CABG. There was no significant difference observed in both groups with long-term all-cause mortality (31 PCI vs 21% MICS-CABG, p=0.151) and the overall 5 year survival was similar on Kaplan-Meier curve (Log rank p=0.318). The average length of stay in hospital was significantly shorter in the PCI than in the MICS-CABG group (4.3 vs 7.8 days, p<0.001). Only 4.7% of the PCI group were discharged to rehabilitation facility compared with 43.9% of the MICS-CABG group (p<0.001). The rate of repeat revascularization was significantly higher in the PCI group than in the MICS-CABG group (15 vs 3%, p=0.014). CONCLUSION: Among elderly patients, long-term all-cause mortality is similar after PCI and MICS-CABG. However, there is a significantly higher rate of repeat revascularization after PCI.

Identification of Risk Factors for Cervical Spine Injury from Pediatric Trauma Registry.

BACKGROUND: Cervical spine injuries are rare in children. Our goal is to establish guidelines for cervical spine clearance that are practical for our pediatric population, and, in the process, to reduce the risk of radiation exposure from unnecessary advanced imaging. METHODS: We retrospectively reviewed the records from the registries of two pediatric trauma centers from the past 11 years (January 2002 to June 2013). Patients aged 1 month to 17 years, who had a CT scan of the cervical spine due to trauma indication for possible cervical spine injury, were evaluated. RESULTS: Three risk factors were identified as being significant for the presence of a cervical spine injury. Patients who sustained a cervical spine injury were more likely to be male (p = 0.0261), were more severely injured with a higher injury severity score (ISS 16.39 ± 15.79 injured vs. 8.7 ± 9.4 uninjured), and presented with neck tenderness (p = 0.0001). CONCLUSION: In our study, significant cervical spine injury is related to male gender, higher ISS and neck tenderness.

Hyperplastic cardiac sarcoma recurrence.

Primary cardiac sarcomas are rare tumors with a median survival of 6-12 months. Data suggest that an aggressive multidisciplinary approach may improve patient outcome. We present the case of a male who underwent resection of cardiac sarcoma three times from the age of 32 to 34. This report discusses the malignant nature of cardiac sarcoma and the importance of postoperative multidisciplinary care.

Minimally Invasive Valve Surgery and Single Vessel Coronary Artery Bypass via Limited Anterior Right Thoracotomy.

BACKGROUND: Coronary artery bypass grafting with aortic valve replacement (AVR) or mitral valve replacement (MVR) is traditionally performed via sternotomy. Minimally invasive coronary surgery (MICS) and minimally invasive valve surgery have been successfully performed independently. Patients with critical right coronary artery (RCA) stenosis not amenable to percutaneous intervention are candidates for valve replacement and single vessel coronary artery bypass. We present our series of six patients who underwent a concomitant valve and single vessel intervention via right thoracotomy. METHODS: Between January 2011 and June 2013, six patients underwent right thoracotomy with valve replacement and single vessel bypass. Four aortic and two mitral valves were replaced and all received single vessel RCA bypass using reversed saphenous vein graft. Thoracotomy was via right anterior approach for AVR and right lateral for MVR. The patients were assessed postoperatively for overall outcomes. RESULTS: The average age was 74 years (range 69-81); two patients were elective (AVR-1; MVR-1) and four were urgent (AVR-3; MVR-1). For MICS AVR and MICS MVR, the average cardiopulmonary bypass time was 171 ± 30 and 169 ± 7 minutes and the average aortic cross-clamp time was 122 ± 36 and 112 ± 2 minutes, respectively. Three patients were discharged home, one patient to a nursing home, and two to rehab. No patients required conversion to sternotomy; one patient developed atrial fibrillation, and one sepsis. CONCLUSION: Concomitant valve replacement and single bypass grafting via right anterior mini-thoracotomy is a viable option for select patients, particularly in non-stentable RCA stenosis. In the appropriate patient population, combined coronary artery bypass grafting and valve surgery can be safely performed via right thoracotomy.

Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients).

OBJECTIVES: Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD. METHODS: This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index. RESULTS: Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses. CONCLUSIONS: The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.

Twenty-four hour staged carotid endarterectomy followed by off-pump coronary bypass grafting for patients with concomitant carotid and coronary disease.

BACKGROUND: Carotid artery stenosis and coronary artery disease share common risk factors and often coexist in the same patient. Currently, no consensus exists regarding the optimal treatment strategy for patients with concomitant severe coronary and carotid disease. We reviewed the results of our experience performing off-pump coronary artery bypass grafting (CABG) within 24 hours of carotid endarterectomy (CEA) in this select patient population. METHODS: In this single institution retrospective study we identified patients who underwent CEA followed by CABG from March 2001 to March 2012. Preoperative, intraoperative, and postoperative data were collected and analyzed. RESULTS: Ninety patients underwent CEA followed by off-pump CABG. The duration between CEA and CABG was 1.8±5.6 days with 80 (89%) within 24 hours. Mean age was 69±9 years, 68% male. Perioperative comorbidities included hypertension (87%), diabetes (50%), previous myocardial infarction (24%), peripheral arterial disease (20%), and strokes and transient ischemic attack (16%). Extensive aortic atherosclerosis was noted in 15 patients (17%). The average number of vessels bypassed was 3.4±1.0, and the average number of proximal vein aortotomies was 1.7±0.92. Post-CEA surgical outcomes were myocardial infarction (1%), acute embolic cerebrovascular accident (1%), left upper extremity weakness (1%), and hypoglossal nerve injury (1%). Post-CABG surgical outcomes included atrial fibrillation (34%), anemia (12%), pneumothorax (7%), and postoperative bleeding (4%). No post-CABG cerebrovascular accident was identified. Patients were discharged 7.5±3.5 days after CEA. CONCLUSIONS: Twenty-four hour staged CEA followed by CABG minimizes myocardial infarction post-CEA while minimizing cerebrovascular accident post-CABG in patients with concomitant severe coronary and carotid artery disease.

Results of the Minimally Invasive Coronary Artery Bypass Grafting Angiographic Patency Study.

OBJECTIVE: Minimally invasive coronary artery bypass grafting is safe and widely applicable, and may be associated with fewer transfusions and infections, and better recovery than standard coronary artery bypass grafting. However, graft patency rates remain unknown. The Minimally Invasive Coronary Artery Bypass Grafting Patency Study prospectively evaluated angiographic graft patency 6 months after minimally invasive coronary artery bypass grafting. METHODS: In this dual-center study, 91 patients were prospectively enrolled to undergo minimally invasive coronary artery bypass grafting via a 4- to 7-cm left thoracotomy approach. The left internal thoracic artery, the ascending aorta for proximal anastomoses, and all coronary targets were directly accessed without endoscopic or robotic assistance. The study primary outcome was graft patency at 6 months, using 64-slice computed tomography angiography. Secondary outcomes included conversions to sternotomy and major adverse cardiovascular events (Clinical Trial Registration Unique identifier: NCT01334866). RESULTS: The mean age of patients was 64 ± 8 years, the mean ejection fraction was 51% ± 11%, and there were 10 female patients (11%) in the study. Surgeries were performed entirely off-pump in 68 patients (76%). Complete revascularization was achieved in all patients, and the median number of grafts was 3. There was no perioperative mortality, no conversion to sternotomy, and 2 reopenings for bleeding. Transfusion occurred in 24 patients (26%). The median length of hospital stay was 4 days, and all patients were followed to 6 months, with no mortality or major adverse cardiovascular events. Six-month computed tomography angiographic graft patency was 92% for all grafts and 100% for left internal thoracic artery grafts. CONCLUSIONS: Minimally invasive coronary artery bypass grafting is safe, feasible, and associated with excellent outcomes and graft patency at 6 months post-surgery.

Minimally invasive coronary artery bypass grafting: is it time for the robot?

PURPOSE OF REVIEW: Minimally invasive coronary artery bypass grafting (MICS CABG) consists of single-vessel or multivessel revascularization via a small left thoracotomy, and has been proposed as an alternative to a standard sternotomy approach. The purpose of this article is to examine the current status of MICS CABG and discuss its future directions. RECENT FINDINGS: Experience in the first 450 cases was reported in 2009, and established the efficacy and safety of a small thoracotomy approach for multivessel and single-vessel revascularization. In addition to earlier recovery and rehabilitation, MICS CABG is associated with fewer transfusions and fewer wound infections than off-pump CABG. Recently, the MICS CABG Patency Study showed excellent graft patency in patients assessed by 64-slice computed tomography angiography 6 months after operation. We also showed that the use of cardiopulmonary bypass assistance may help alleviate some of the learning curve inherent in this operation. SUMMARY: MICS CABG has developed into a reproducible, high-quality, complete surgical revascularization alternative to conventional CABG. Preservation of sternal integrity allows patients to recover earlier, require fewer transfusions, and experience fewer infections. Further research on expanding the applicability of MICS CABG and enhancing its advantages over conventional CABG is warranted.

Elevated preoperative neutrophil/lymphocyte ratio as a predictor of increased long-term survival in minimal invasive coronary artery bypass surgery compared to sternotomy.

BACKGROUND: Neutrophil lymphocyte ratio (NLR) is a predictor of major adverse cardiovascular outcomes. Our study explores the value of NLR in predicting long-term mortality after minimally invasive coronary artery bypass surgery (MICS) via lateral left-thoracotomy versus conventional sternotomy coronary artery bypass grafting (CABG) surgery. METHODS: A total of 1126 consecutive patients (729 sternotomy CABG and 397 MICS) from a single tertiary center between 2005 and 2008 were followed until 2011. We stratified the patients into equal tertiles according to preoperative NLR. The primary outcome, all-cause mortality, was compared among the NLR tertiles. RESULTS: Out of the 1126 patients included in the study, 1030 (91%) patients underwent off-pump CABG . The first (NLR <2.3) tertile had a significantly lower 5-year mortality (30/371 =8%) in comparison to the second (NLR =2.3-3.4) and third (NLR ≥3.5) tertiles (49/375 =13% and 75/380 =20%), respectively with p < 0.0001. After multivariate adjustment, NLR was a significant independent predictor of mortality (hazard ratio [HR] per each unit increase of NLR was 1.05, 95% confidence interval [CI] 1.01-1.10, p = 0.008). MICS and sternotomy CABG groups with NLR <3 had similar mortality (21/221 =9.5% and 40/403 =9.9%), p = 1. However among patients with NLR ≥3, MICS had a significantly lower mortality (23/176 =13.1%) compared to the sternotomy CABG (70/326 =21.5%), p = 0.02. According to the multivariate analysis of patients with NLR ≥3, MICS had a significantly lower mortality compared to sternotomy CABG (HR = 0.44, 95% CI 0.24-0.78, p = 0.005). CONCLUSION: Elevated preoperative NLR is an independent predictor of long-term mortality after CABG. Among the patients with NLR ≥ 3, MICS was associated with a significantly improved survival compared with sternotomy CABG.

Experience with a minimally invasive approach to combined valve surgery and coronary artery bypass grafting through bilateral thoracotomies.

BACKGROUND: Minimally invasive coronary artery bypass grafting (MICS-CABG) and minimally invasive valve surgery (MIVS) have been used independently to manage occlusive coronary artery disease and valvular diseases, respectively. We present 12 patients who underwent combined MICS-CABG and MIVS via bilateral mini-thoracotomies. METHODS: We retrospectively reviewed 116 consecutive valve/CABG operations by a single surgeon and compared the outcomes obtained via sternotomy with those obtained via bilateral minithoracotomies. RESULTS: Six patients in the MIVS group underwent aortic valve replacement (sternotomy group, n = 70), 3 patients underwent mitral valve repair (sternotomy group, n = 9), and 3 underwent mitral valve replacement (sternotomy group, n = 25). The minimally invasive valve surgeries were combined with MICS-CABG for single- (n = 2), double- (n = 9), and triple-vessel (n = 1) coronary artery disease in a single operation. The mean SD duration of cardiopulmonary bypass was 164 ± 44.6 minutes (mean time via sternotomy, 152 ± 50.5 minutes; P = .4146), and the mean aortic cross-clamp time was 87.8 ± 22.1 minutes (mean time via sternotomy, 105 ± 39.8 minutes; P = .1455). The use of perioperative blood transfusions averaged to 2.3 ± 5.6 units (mean usage via sternotomy, 2.7 ± 4.9 units; P = .8326). There were no conversions to sternotomy in the minimally invasive group. Patients in the minimally invasive group were extubated earlier (24 ± 11 hours; sternotomy group, 40 ± 61 hours; P = .3684) and discharged earlier (7 ± 4 days) than patients who underwent median sternotomy (9 ± 10 days; P = .4027). CONCLUSION: MICS-CABG combined with MIVS via bilateral minithoracotomies yielded short-term results comparable to those for CABG and valve repair via median sternotomy. There were no operative mortalities or reoperations. The possible advantages of the minimally invasive approach included earlier extubation and earlier discharge from the hospital. Combined CABG and valve surgery can be safely performed via bilateral thoracotomies.