Midterm outcomes of off-pump and on-pump coronary artery revascularization in renal transplant recipients.

OBJECTIVES: Renal transplant recipients have high mortality from cardiac causes and are frequently in need of coronary interventions. Surgical coronary revascularization is associated with significant morbidity and mortality in this patient population. This study was undertaken to evaluate outcomes of on-pump versus off-pump revascularization in renal transplant recipients. METHODS: We retrospectively reviewed 43 renal transplant recipients who underwent surgical coronary revascularization with functioning allografts. Revascularization was performed on-pump [coronary artery bypass grafting (CABG)] in 21 patients and off-pump [off-pump coronary artery bypass (OPCAB)] in 22 patients. RESULTS: Preoperative characteristics did not differ between the two groups except for age and incidence of prior sternotomy. Total operative time and transfusion requirements were similar. The on-pump group received a higher number of bypass grafts (p = 0.03). Overall 30-day, one-year, five-year, and eight-year survival was 90%, 76%, 61%, and 32% for CABG group, and 95%, 86%, 62%, and 48% for OPCAB group (p = 0.53). The postoperative peak creatinine was higher in the CABG patients than in OPCAB patients (p = 0.04). At discharge, there was no difference in mean creatinine between the two groups. The rate of return to permanent dialysis after revascularization was similar (28% for CABG and 22% for OPCAB, p = 0.73). There was no difference in dialysis-free survival up to eight-years postrevascularization (p = 0.63). CONCLUSIONS: Despite higher mortality risk, surgical coronary revascularization can be performed safely in renal transplant recipients. OPCAB resulted in no improvement in patient survival or renal allograft function compared to on-pump revascularization.

Comparison of inflammatory response during on-pump and off-pump coronary artery bypass surgery.

PURPOSE: On-pump coronary artery bypass graft (CABG) surgery has been traditionally associated with a higher magnitude of inflammatory response than off-pump CABG. However with the development of polymer-coated biocompatible extracorporeal circuits, we wanted to see if cardiopulmonary bypass still played an important role in triggering this inflammatory response. METHODS: In this prospective observational study, 33 patients undergoing CABG surgeries (25 on-pump and 8 off-pump patients) were studied. Serial plasma cytokine (TNF IL-6, IL-10) and procalcitonin concentrations were measured at different time-points during and after the surgery. Demographic and baseline clinical data, intra-operative management details and post-operative complications were also collected from the patients' charts. RESULTS: Plasma levels of all 4 mediators increased during surgery and returned towards normal postoperatively. There were no differences between groups for any mediator at any time-point. CONCLUSIONS: We conclude that with the use of recent polymer-coated biocompatible extracorporeal circuits, the inflammatory response triggered by on-pump CABG becomes very similar in magnitude and pattern to that triggered by off-pump CABG. Thus, the surgical procedure contributes to most of the inflammatory response, with the extra-corporeal circuit having minimal to no effect on this response.

A novel percutaneous solution to limb ischemia due to arterial occlusion from a femoral artery ECMO cannula.

PURPOSE: To describe a novel percutaneous technique for distal limb perfusion in the face of femoral artery occlusion secondary to extracorporeal membrane oxygenation (ECMO) cannula placement. TECHNIQUE: The technique is described in a 59-year-old man who presented with an inferior wall myocardial infarction and a large ventricular septal defect (VSD) requiring the initiation of ECMO via right femoral artery and vein cannulae. He subsequently developed right lower limb ischemia secondary to cannula occlusion of the femoral artery. Percutaneous transfemoral placement of a flush catheter in the right common femoral artery was performed angiographically. Ischemic symptoms resolved, and the patient was subsequently able to undergo repair of his VSD without any further lower limb ischemic sequelae. CONCLUSION: Percutaneous transfemoral placement of a flush catheter in the common femoral artery distal to ECMO cannula insertion has not to our knowledge been reported and carries the added benefit of restoring perfusion to both superficial and profunda femoris arteries.

An unusual clinical presentation resembling superior vena cava syndrome post heart surgery.

BACKGROUND: An unusual sequence of post operative events heralded by hemodynamic deterioration followed by dyspnea and rapidly progressive dilatation of superficial neck and facial veins, resembling a superior vena cava syndrome, two days post surgical resection of filamentous aortic valve masses, closure of a patent foramen ovale, and performance of a modified Maze procedure for atrial fibrillation in a patient that presented with transient neurologic findings is presented. CASE PRESENTATION: Although both clinical findings and hemodynamic derangements completely resolved following tricuspid valve repair aimed to correct the new onset severe tricuspid regurgitation noted post operatively; a clear mechanism was not readily obvious and diagnostic testing data somewhat conflictive. We present a careful retrospective examination of all clinical data and review possible clinical entities that could have been implicated in this particular case and recognize that transesophageal echocardiographic findings were most useful in identifying the best course of action. CONCLUSION: After reviewing all clinical data and despite the inconclusive nature of test results; the retrospective examination of transesophageal echocardiographic findings proved to be most useful in identifying the best course of action. We postulate that in our case, resolution of the suspected pulmonary embolism with anticoagulation and reestablishment of a normal right ventricular geometry with tricuspid valve repair worked in unison in restoring normal hemodynamics and resolving both dyspnea and venous dilatation.

Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass.

BACKGROUND: Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES: To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS: Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS: The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION: Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.