Brain and lower body protection during aortic arch surgery.

BACKGROUND: Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C-28°C (moderately hypothermic circulatory arrest [MHCA]), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming [DR]) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP. METHODS: A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit [PND]), and need of renal replacement therapy (RRT). RESULTS: Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio [OR]: 7.39, confidence interval [CI]: 1.37-79.1) and composite endpoint (OR: 8.97, CI: 1.95-35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group. CONCLUSIONS: The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients.

INTRODUCTION: Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting. METHODS: We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. RESULTS: The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke. CONCLUSION: Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Human Mesenchymal Stem Cells Reendothelialize Porcine Heart Valve Scaffolds: Novel Perspectives in Heart Valve Tissue Engineering.

Heart valve diseases are usually treated by surgical intervention addressed for the replacement of the damaged valve with a biosynthetic or mechanical prosthesis. Although this approach guarantees a good quality of life for patients, it is not free from drawbacks (structural deterioration, nonstructural dysfunction, and reintervention). To overcome these limitations, the heart valve tissue engineering (HVTE) is developing new strategies to synthesize novel types of valve substitutes, by identifying efficient sources of both ideal scaffolds and cells. In particular, a natural matrix, able to interact with cellular components, appears to be a suitable solution. On the other hand, the well-known Wharton's jelly mesenchymal stem cells (WJ-MSCs) plasticity, regenerative abilities, and their immunomodulatory capacities make them highly promising for HVTE applications. In the present study, we investigated the possibility to use porcine valve matrix to regenerate in vitro the valve endothelium by WJ-MSCs differentiated along the endothelial lineage, paralleled with human umbilical vein endothelial cells (HUVECs), used as positive control. Here, we were able to successfully decellularize porcine heart valves, which were then recellularized with both differentiated-WJ-MSCs and HUVECs. Data demonstrated that both cell types were able to reconstitute a cellular monolayer. Cells were able to positively interact with the natural matrix and demonstrated the surface expression of typical endothelial markers. Altogether, these data suggest that the interaction between a biological scaffold and WJ-MSCs allows the regeneration of a morphologically well-structured endothelium, opening new perspectives in the field of HVTE.

Novel apical coring device for apicoaortic conduit insertion to treat off-pump aortic stenosis, coronary disease, and lung cancer.

The surgical treatment of concomitant cardiac disease and lung cancer represents a challenge. We report the case of a 66-year-old high-risk female patient with severe aortic stenosis as well as severely impaired left ventricular function associated with coronary artery disease involving the left anterior descending artery complicated from a severe functional mitral regurgitation in which an early-stage non-small cell carcinoma was incidentally discovered during workup. Because of the possibility of potential negative impact of cardiopulmonary bypass on the cancer prognosis and the severe impairment of systolic function of the left ventricle that impeded the treatment of lung cancer as the first step of such a complex treatment, we planned to treat all the diseases in a single-stage procedure. Using an automated delivering system composed of a ventricular connector (Correx AVB; Correx, Inc, Waltham, MA USA), we were able to perform an apicoaortic bypass as well as a left anterior descending revascularization using the left internal thoracic artery, both on a beating heart without the aid of cardiopulmonary bypass and a three-segmentectomy of the left upper lobe with the removal of paraaortic nodes. Six months postoperatively, she was asymptomatic with a noticeable increase of systolic function, a mild mitral incompetence, and no appearance of tumor recurrence. To the best of our knowledge, this is the first case described in the literature in which three major problems involving cardiac valves, coronary arteries, and the lung have been treated in one stage without cardiopulmonary bypass.

Intraoperative graft verification in coronary surgery: increased diagnostic accuracy adding high-resolution epicardial ultrasonography to transit-time flow measurement.

OBJECTIVES: Transit-time flow measurement (TTFM) allows intraoperative functional assessment of grafts in coronary artery bypass grafting (CABG). The major limitation of this technique is a low positive predictive value (PPV) that could lead to unnecessary graft revisions. A combined approach with high-resolution epicardial ultrasonography (HR-ECUS) and TTFM was evaluated for the first time in terms of diagnostic accuracy. The aim of this study is to evaluate the added value of intraoperative HR-ECUS for an improved graft patency verification. METHODS: From November 2009 to September 2012, 333 patients underwent isolated CABG. A total number of 717 grafts were performed; all grafts were intraoperatively verified by means of both TTFM and HR-ECUS. RESULTS: Among 678 grafts considered functioning at TTFM, 3 (0.4%) were failing at HR-ECUS and promptly redone (2 bilateral internal mammary artery-Y-grafts and 1 left internal mammary artery to left anterior descending (LIMA-LAD)). These were confirmed as true positive at graft revision due to technical error. HR-ECUS confirmed the good functioning of the remaining 675 grafts already demonstrated by TTFM; among them, 8 showed high troponin I release (clinical false negative), whereas the remaining 667 had no high TnI release (clinical true negative). In 2 of 39 grafts malfunctioning at TTFM, HR-ECUS confirmed the graft failure; surgical inspection of the anastomosis during redo procedure (in both cases LIMA-to-LAD graft) showed a technical error leading to define those 2 grafts as 'true positive' on the basis of either direct vision and improved post-redo TTFM parameters. Finally, in 35 cases, HR-ECUS did not confirm TTFM diagnosis demonstrating a full patency of the anastomosis; these grafts had an uneventful clinical course (true negative). The main result of this study is the increase of PPV from 10% with TTFM to almost 100% of TTFM + HR-ECUS, avoiding many unnecessary graft revisions. CONCLUSIONS: HR-ECUS should be considered complimentary to TTFM. Simultaneous use of the two methods during CABG provides morphological and functional information improving considerably diagnostic accuracy of intraoperative graft verification procedure close to 100%.

Pseudoaneurysm after patch-free carotid bifurcation endarterectomy: a case report.

The purpose of this report is to present the case of a 59-year-old man affected by multivessel coronary artery disease and sterile pseudoaneurysm of the right carotid bifurcation presenting as a pulsating neck mass 1 month after patch-free carotid endarterectomy. The surgical approach included median sternotomy and incision parallel to the anterior margin of the right sternocleidomastoid muscle. The pseudoaneurysm was excised after control of the brachiocefalic trunk and insertion of a Pruit-Inahara shunt, and the carotid vessels were directly sutured without using any prosthetic or autologous material. Concomitant coronary bypass grafting was performed. The postoperative course was uneventful and there was no evidence of recurrence of pseudoaneurysm at 6-month follow-up. On the basis of this experience and of pertinent literature, the options for the management of such rare entities are discussed.

Recurrence of functional mitral regurgitation in patients with dilated cardiomyopathy undergoing mitral valve repair: how to predict it.

This study was aimed at identifying predictive variables for recurrence of mitral regurgitation (MR) in patients with dilated cardiomyopathy (DCM) undergoing mitral valve (MV) repair. From January 1997 to December 2005, 142 patients with DCM, 105 (73.9%) ischemic and 37 (26.1%) non-ischemic, underwent MV repair. Mean age was 66+/-10 years and mean MR grade was 3.2+/-0.7 (scale 1+ to 4+). Ninety-seven (71% ischemic, 29% non-ischemic), out of 98 still alive at follow-up, were included in this retrospective analysis. In all cases MV posterior annuloplasty was performed; all patients were followed-up by echocardiography (mean time interval of 44+/-28 months) to evaluate MR recurrence (>or=2+/4+). Thirty-day mortality was 9.2% (13 patients). Mean MR grade at follow-up was 0.9+/-0.9. Four-year freedom from MR recurrence was 65.5%+/-8.3. Cox analysis showed left ventricular end-diastolic volume index (LVEDVi, OR=1.03, P=0.016, AUC=0.72), left ventricular end-systolic volume index (LVESVi, OR=1.03, P=0.033, AUC=0.71), left ventricular ejection fraction (LVEF, OR=0.82, P=0.001, AUC=0.72), mitral valve coaptation depth (MVCD, OR=1.6, P=0.017, AUC=0.72) to be predictive variables for MR recurrence. Preoperative left ventricular dilatation and function along with degree of papillary muscle displacement can be helpful in identifying patients with higher probability to undergo a durable MV repair.

Evaluation of less invasive method for saphenous vein harvest in patients with type II diabetes.

BACKGROUND: Diabetes mellitus is an established risk factor for leg wound healing complications after great saphenous vein harvest. Leg healing complications occur in 1-25% of coronary artery bypass graft patients, and are often underestimated. PATIENTS AND METHODS: The records of 230 patients enrolled in a prospective trial to evaluate a minimally invasive approach compared with conventional longitudinal harvest were reviewed. Of 100 patients with diabetes, 49 had undergone minimally invasive harvest (group A). Forty-nine patients from the pool without diabetes who underwent minimally invasive harvest were selected using propensity scoring analysis (group B), and 46 diabetic patients operated using a conventional technique (group C) were matched to group A patients. Ninety-five patients with and 49 without diabetes finally entered the study. The quality of leg wound healing was quantified by ASEPSIS score by two independent surgeons in a blinded manner. The occurrence of complications was compared between groups. RESULTS: Fewer leg wound healing complications occurred in diabetic patients in the minimally invasive compared with the conventional group (P < 0.0001). Rates of complications were comparable among diabetic and non-diabetic patients operated using the minimally invasive technique. The intraoperative flow of vein grafts obtained by the minimally invasive technique was comparable to that of veins harvested using the conventional technique. CONCLUSION: These data suggest that postoperative leg wound morbidity can be significantly attenuated by the adoption of a less invasive approach, even in high-risk patients with diabetes. The advantages are not offset by the co-existence of other cardiovascular risk factors or by a long history of diabetes.

Open clip-free radial artery harvesting with the harmonic shears.

BACKGROUND: The Ultracision Harmonic Scalpel is associated with several advantages in radial artery (RA) harvesting. It allows fewer hemostatic clips to close the collateral branches, less thermal injury of the conduit, and reduced time of harvesting in comparison with the conventional RA harvesting technique with electrocautery and hemostatic clips. We recently started open RA harvesting with the harmonic shears (HSH). In this study, we aimed at evaluating the feasibility of this simplified ultrasonically activated harvesting technique, and report the results of RA harvesting with HSH. METHODS: The RA harvesting with HSH was performed in 20 patients operated on for myocardial revascularization from July 2004 to December 2005. RESULTS: The harvest of the RA was completed in little time, without any complication. Neither bleeding from the collateral branches nor spasm alongside the entire length of the RA was observed. No bleeding occurred from the muscles of the forearm. CONCLUSION: This technique of RA harvesting with HSH is impressive in terms of short time of harvest, complete absence of clips for the collateral branches, and no thermal injury of the conduit.

The "button inside" technique for the aortic root replacement: a modified button technique.

Modified button technique for reattachment of coronary arteries in the aortic root replacement is reported. Anastomosis of the coronary buttons is performed from the inside of the composite valve graft previously including the coronary buttons in the composite valve graft. Reduced tension is present between coronary arteries and the composite valve graft once the heart is beating and the systemic pressure is increasing. In this way coronary buttons are reinforced directly by the composite aortic wall graft prosthesis. The coronary ostia are perfused with lower tension at the site of the coronary anastomoses. No bleeding from the suture line of the coronary buttons occurs using this new surgical approach.

Repair of acute postinfarct posterior ventricular septal rupture without left ventriculotomy: a stable suture preserving left ventricular geometry.

The present article describes the case of a man operated upon for emergency closure of an acute postinfarction defect in the posterior septum. We used a novel technique. The rupture was approached by disconnection of the right ventricular posterior free wall with the exposure of the right side of the septum. First, the edges of the defect were joined together by a single purse-string pledgetted suture. Then an on-site tailored double-folded patch was applied with the aim of closing both the septal defect and the RV access. In our limited experience the technique proved to be safe and effective, allowed optimal exposure of the defect and placement of stable stitches, reducing postoperative complications.

Thoracic radiation therapy and suitability of internal thoracic arteries for myocardial revascularization.

INTRODUCTION AND BACKGROUND: Myocardial revascularization using internal thoracic arteries (ITAs) has been associated with superior clinical outcome. This study addresses the question of whether internal mammary arteries are unsuitable for grafting due to radiation-based damage in patients with history of thoracic radiation therapy. We review our experience in this subset of surgical candidates. PATIENTS AND METHODS: Forty-nine patients undergoing elective coronary artery bypass grafting with use of at least one ITA were enrolled and matched to 49 comparable nonirradiated individuals by propensity scoring system. Preoperative and postoperative data were collected and compared. A 18-month clinical follow-up was performed. RESULTS: Intraoperative mammary artery flow was assessed by transthoracic Doppler echocardiography probe, and there was no significant difference between irradiated and nonirradiated individuals (36 +/- 8.3 mL/min vs 39 +/- 7.2 mL/min, p = 0.15). The two study groups were also comparable in terms of survival (overall mortality, 2%) and recurrence of angina and perfusion defect at control stress perfusion nuclear scan (p = 0.99 and p = 0.77, respectively). One arterial graft showed stenosis at postoperative angiography. The dose of radiation therapy administered did not correlate with graft flow values after anastomosis. CONCLUSION: Our data suggest that the use of a monolateral or bilateral ITA is not associated with early graft failure in patients with history of chest/mediastinal irradiation. Skeletonization harvesting technique might be recommended because of the frequent presence of fibrous tissue around the in situ vessel. Arterial graft stenosis in thorax-irradiated patients should be attributed to the primary atherosclerotic disease rather than to irradiation itself.

Midterm angiographic patency and vasoreactive profile of proximal versus distal radial artery grafts.

BACKGROUND: No data are available on the different angiographic results and the in vivo vasoreactivity of radial artery (RA) grafts obtained from different parts of the conduit, although it is known that the distal segment of the artery has a more pronounced muscular component. This study was conceived to evaluate the angiographic patency and tendency to spasm of proximal versus distal RA grafts. METHODS: In 29 patients, at the time of surgical myocardial revascularization, the radial artery was divided into two separate conduits, so that these patients received a total of 58 radial grafts (29 from the proximal and 29 from the distal portion of the artery). All cases were submitted to midterm angiography and vasoactive challenges to verify angiographic patency and vasoreactive profile. RESULTS: Radial artery patency rate was 28 of 29 for both groups. Nine cases of string sign were reported, all in the distal series (p = 0.001). The perfect patency rate of distal grafts was markedly lower than that of proximal grafts (19 of 29 versus 27 of 29; p = 0.02). Vasoactive challenges testified to a higher vasospastic attitude of distal grafts. CONCLUSIONS: Radial artery grafts obtained from the distal portion of the artery have a higher vasospastic tendency, greater incidence of string sign, and lower midterm perfect patency rate than graft taken from the more proximal part of the artery. The proximal part of the RA should be preferred for use as a conduit for surgical myocardial revascularization.

Is postoperative calcium channel blocker therapy needed in patients with radial artery grafts?

BACKGROUND: Chronic calcium channel blocker therapy has traditionally been considered necessary in patients carrying a radial artery graft, even in the absence of objective data to support it. This report was conceived to evaluate the angiographic and clinical effects of calcium channel blocker therapy during the first postoperative year. PATIENTS AND RESULTS: A total of 100 consecutive patients who received a radial artery graft at our institution were randomly assigned to receive (n = 53) or not receive (n = 47) calcium channel blocker therapy with oral diltiazem 120 mg/daily started in the early postoperative period. At 1-year follow-up, all patients were reassessed clinically and by Tl 201 myocardial scintigraphy, and 83 of them underwent control angiography. In 12 cases we also evaluated the response of the radial artery to the endovascular infusion of serotonin. No difference in terms of clinical outcome, scintigraphic results, and patency rate was found between patients who received or did not receive calcium channel blocker therapy. Endovascular serotonin infusion evoked an evident spastic reaction of radial artery grafts, not attenuated by calcium channel blocker therapy. CONCLUSION: Calcium channel blocker therapy started immediately after surgery and continued for the first postoperative year does not affect radial artery graft patency and clinical and scintigraphic outcomes. On the basis of these data, the prophylactic use of calcium channel blocker therapy in patients with radial artery grafts seems unsubstantiated.

Survival after aortic valve replacement for aortic stenosis: does left ventricular mass regression have a clinical correlate?

AIM: The effects of post-operative left ventricular mass regression (LVMR) on clinical outcome after aortic valve surgery remains to be established. This study was intended to establish the impact of patient characteristics on post-operative survival in patients referred for aortic valve replacement (AVR), with particular regard to LVMR. METHODS AND RESULTS: Two hundred and sixty consecutive cases submitted to aortic valve replacement for valvular stenosis were prospectively followed for a mean of 28+/-9 months. Baseline, characteristics and extent of LVMR were tested for association with survival by uni- and multivariable analysis. Ten deaths occurred during hospital stay and 52 during out-of-hospital follow-up. Mean left ventricular mass decreased from 190+/-43 to 158+/-70 g/m2 (P<0.001). Older age, advanced functional class, hypertension, reduced left ventricle ejection fraction, and high pre-operative left ventricular mass index were associated with reduced survival. Overall the extent of LVMR did not influence the clinical results, while only early (<6 months) LVMR was weakly associated with mid-term outcome. CONCLUSION: Survival after aortic valve surgery is mainly determined by the pre-operative functional cardiac and systemic status. The extent of LVMR does not correlate with clinical outcome, whereas aggressive treatment of hypertension may improve post-operative survival.

Surgical Treatment of Mitral Valve Regurgitation in Dilated Cardiomyopathy.

Abstract Background: Mitral valve (MV) surgery for dilated cardiomyopathy (DCM) was proposed at the beginning of the 1990s, and its effectiveness has been confirmed by many studies. The aim of this study is to evaluate long-term survival and the functional results of our experience with MV surgery for DCM. Methods: From January 1990 to October 2002, MV surgery for DCM was performed in 91 patients (64 ischemic, 27 idiopathic). DCM was defined as in our previous reports. Patients with organic MV disease, severe right ventricle dilatation with impaired function, or severe renal or hepatic failure were excluded from the study. MV annuloplasty was performed in 64 patients, and 27 patients underwent a MV replacement. Results: The 30-day mortality rate was 4.4% (4 patients). The probability of being alive at 5 years was 78.4% +/- 4.3% and was higher in patients who underwent MV repair (81.4% +/- 4.5%) than in patients who underwent replacement operation (66.7% +/- 9.1%), even if the P value was not statistically significant. After a mean follow-up period of 27 +/- 30 months, the New York Heart Association (NYHA) class decreased from 3.5 +/- 0.7 to 2.1 +/- 0.6 in the 69 survivors ( P <.001). The probability of being alive 5 years after surgery with an improvement of least 1 NYHA class was 65.9% +/- 5.0% and was higher in patients with MV repair (76.6% +/- 6.0%) than in patients who underwent valve replacement (51.9% +/- 9.6%), even if the P value was not statistically significant. Fifty patients were carefully followed with serial evaluations in our echocardiographic laboratory. Volumes did not change, nor did stroke volume or ejection fraction. Some degree of functional mitral regurgitation (FMR) was present in all but 8 of the patients who underwent repair. The analysis of these patients showed that all of the patients who had no residual MR had a mitral valve coaptation depth (MVCD) of 10 mm or less and had a better functional result. Conversely, the MVCD was shorter in patients who had no or mild (1/4) residual MR than in patients who had a residual MR >1/4. NYHA class was lower in patients with no or up to 1/4 residual MR, showing that the purpose of the procedure is the reduction or elimination of FMR, which is the determinant of the clinical result. Conclusions: Long-term results in our patients are satisfying. FMR can be crucial for achieving a higher effectiveness of a combined strategy to improve the global outcome of these patients.

Myocardial revascularization with and without cardiopulmonary bypass: advantages, disadvantages and similarities.

OBJECTIVES: Off-pump coronary artery bypass surgery is becoming increasingly popular although its effectiveness remains controversial. Our goal was to investigate the effectiveness of on-pump and off-pump coronary artery bypass surgery on early (30 days) and long-term (5 years) clinical outcome in two groups of patients selected using propensity scores. METHODS: From November 1994 to December 2001, 4381 patients underwent isolated coronary surgery. Applying propensity score matching, 1922 patients were selected (off-pump n=961, on-pump n=961). RESULTS: Stepwise logistic regression analysis showed that the use of cardiopulmonary bypass was an independent predictor for early death, cerebral vascular accident, early negative primary endpoints (ENPEP), and early major events (EME). Five years freedom from both events was similar in the two groups. However, freedom from acute myocardial infarction (AMI) in grafted areas was higher in the off-pump than in the on-pump patients, a possible explanation being the lower postoperative creatine kinase myocardial band (CKMB) release. Grouping all patients according to CKMB peak release also showed that patients with normal release values had higher freedom from all cardiac events investigated. A subgroup analysis of 59 patients converted from off-pump to on-pump showed higher early mortality, ENPEP, and EME. Conversion, however, did not affect late clinical outcome. CONCLUSIONS: These results suggest that off-pump surgery reduces early mortality and morbidity. Conversion to on-pump carries high in-hospital mortality and morbidity. Long-term clinical outcome is similar in the two groups; however, off-pump patients seemed to have a higher freedom from AMI in the grafted area which might be related to the lower CKMB peak release when compared with patients undergoing on-pump surgery.

Immediate flow reserve of Y thoracic artery grafts: an intraoperative flowmetric study.

OBJECTIVES: Use of both internal thoracic arteries in a Y graft configuration can raise concerns about the possibility of the single left internal thoracic artery being able to meet the flow requirements of two or three distal territories. We evaluated intraoperatively the flow reserve of a Y thoracic artery graft distally anastomosed to the anterior and lateral territories. METHODS: In 21 patients who had Y thoracic artery grafts, the flow was measured in the main stem of the left internal thoracic artery, in the left internal thoracic artery branch, and in the right internal thoracic artery. A transit time Doppler flowmeter was used. Measurements were repeated after the injection of a bolus of 20 mug/kg dobutamine. RESULTS: At baseline condition, the mean blood flow was 44.8 +/- 24.2, 23.4 +/- 11.5, and 21.4 +/- 15.3 mL/min in the main stem of the left internal thoracic artery, in the left internal thoracic artery branch, and in the right internal thoracic artery, respectively. After dobutamine injection, these values increased to 93.2 +/- 49.8, 46.1 +/- 22.6, and 42.5 +/- 31.2 mL/min, respectively. Flow reserve was 2.1 +/- 0.6, 2.2 +/- 0.9, and 2.1 +/- 0.9 mL/min, respectively. CONCLUSIONS: Intraoperative injection of dobutamine increases the flow in the Y thoracic graft by more than two times, not only in the main stem but also in each branch. This finding attests to the safety of Y thoracic conduits in terms of hemodynamic potential.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of strategy on midterm outcome.

BACKGROUND: In a previous study, we demonstrated that patients with multivessel disease benefit during the first postoperative month from elimination of cardiopulmonary bypass (CPB). We evaluated the midterm results of the same patients excluding the first postoperative month from the analysis. METHODS: From May 1997 to November 2000, 1,802 patients with multivessel disease survived the first postoperative month; 906 were operated on without (group A) and 896 with (group B) CPB. Follow-up ranged from 23 to 65 months (mean, 42 +/- 12 months). Four-year actuarial freedom from the following events was evaluated: death from any cause; cardiac death; acute myocardial infarction (AMI) in any territory; AMI in a grafted area; redo percutaneous transluminal coronary angioplasty (PTCA); redo PTCA in a target vessel; cardiac events (death from a cardiac cause, acute myocardial infarction on grafted vessel, redo PTCA on target vessel); and any event. RESULTS: No statistical difference was found between groups A and B with regard to freedom from any death (95.3 +/- 0.8 vs 95.7 +/- 0.7, p = 0.5160); from cardiac death (97.3 +/- 0.6 vs 97.5 +/- 0.6, p = 0.5345); from AMI (98.4 +/- 0.4 vs 98.7 +/- 0.4, p = 0.4655); from AMI in a grafted area (98.9 +/- 0.4 vs 98.7 +/- 0.4, p = 0.9374); from redo PTCA (97.9 +/- 0.5 vs 97.7 +/- 0.6, p = 0.8485); from redo PTCA in a grafted area (98.7 +/- 0.4 vs 98.5 +/- 0.5, p = 0.8774); from target cardiac events (95.8 +/- 0.7 vs 95.9 +/- 0.8, p = 0.6070); and from any event (92.9 +/- 0.9 vs 93.4 +/- 1.0, p = 0.3721). CONCLUSIONS: After exclusion of the first postoperative month, myocardial revascularization without CPB has midterm results similar to myocardial revascularization with CPB. In particular, failure of revascularization does not depend on intraoperative strategy.

Optimal length of pericardial strip for posterior mitral overreductive annuloplasty.

Our recent experience with an autologous pericardium strip to obtain an overreducing posterior mitral annuloplasty is reported. From March 2001 to May 2002, 31 patients underwent this procedure to correct functional (n = 19) or postischemic (n = 12) mitral regurgitation. The length of the pericardium strip was always 4 cm; mean final mitral area was 2.9 cm2, with a mean gradient of 2.9 mm Hg. Eight patients underwent a stress test. Mitral area increased from 3.1 to 3.6 cm2, and the mean gradient increased from 3.1 to 5.2 mm Hg. Residual mitral regurgitation was 0.5 and, when present, remained unchanged at the end of the stress. Overreducing posterior mitral annuloplasty by using a 4-cm pericardial strip gives reproducible results and is effective in correcting functional or postischemic mitral regurgitation. Residual mitral regurgitation, when present, remains stable after stress.