Simultaneous hybrid carotid stenting and coronary bypass surgery versus concomitant open carotid and coronary bypass surgery: a pilot, feasibility study.

OBJECTIVES: Concomitant carotid and cardiac surgery carries an increased perioperative morbidity and mortality risk. Whether the hybrid procedure of carotid artery stenting (CAS) and coronary bypass surgery decreases the risk of stroke and other complications is still unknown. The aim of this study was to assess early outcomes after simultaneous hybrid CAS and coronary bypass grafting versus open concomitant carotid and coronary bypass surgery. METHODS: We included 20 patients in this study. According to the protocol, all the patients were divided into two groups: Group 1 (10 patients) with hybrid CAS and coronary bypass surgery and Group 2 (10 patients) with concomitant carotid and coronary surgery. Different preoperative, intraoperative and postoperative variables were compared. The primary end point was combined incidence of stroke and death 30 days after surgery or during initial hospitalization. The secondary end points were myocardial infarction, atrial fibrillation, blood loss and need for blood transfusion and duration of intensive care unit and hospital stay. RESULTS: Groups 1 and 2 were similar in preoperative characteristics including age (65.3 ± 6.8 vs 70.7 ± 7.0, P = 0.191) New York Heart Association class (2.3 ± 0.5 vs 1.8 ± 0.7, P = 0.218), EuroSCORE (2.8 ± 2.0 vs 3.6 ± 2.3, P = 0.547), the degree of carotid stenosis (79 ± 12 vs 87 ± 13%, P = 0.224) and average left ventricular ejection fraction (44.3 ± 12.4 vs 43.4 ± 13.3%, P = 0.896). Also, the groups did not differ in intraoperative variables with an exception of extracorporeal circulation time (65.7 ± 14.1 vs 90.0 + 17.4 min, P = 0.023), which was significantly shorter in Group 1. Although rare, and without significant difference, primary end point occurred only in Group 2 (1 stroke and 1 death, 20%). There was no difference in the duration of mechanical ventilation, need for transfusion and duration of intensive care unit and hospital stay between the two groups. CONCLUSIONS: Although limited by a small sample size, our results show that the hybrid procedure of carotid stenting and coronary surgery might be a good therapeutic option but further extended studies are needed to assess its real value.

[Prospects of cardioprotection by volatile anesthetics].

Myocardial ischaemia is followed by some reversibile or ireversibile changes. The aim of cardioplegia is to protect numerous intracellular processes: to spare the intracellular energy stores, to reduce the free oxygen radicals synthesis, to protect the function of the endothelium and myocardial oxygen balance as well as ionic balance. The crystalloid or blood cardioplegia, with anterograde or retrograde infusion, is a basic procedure of the intraoperative cardiac protection. Glucose-insulin-potassium solution was primarily used in a myocardial infarction. After the first promising results, some surgical teams started to use the high glucose-insulin-potassium solution, as a metabolic modulation approach, during a coronary surgery as addition to cardioplegia. During ischaemia, a number of intracellular mechanisms deteriorate with bioenergy misbalance and decrease of cellular functional reserve. In particular, the regulation of contractility in response to loading, alteration in autocrine or paracrine regulation in metabolically stressed hearts and acquired, "learned" tolerance of muscle to deteriorate perfusion (preconditioning) are examples of a variety of the cardiac adaptation. The further improvement in the metabolic modulation during a coronary surgery was made with fluorine ion halogenated volatile aneasthetics used for anaesthesia. The results of some experimental and first clinical studies induced a new approach to the modulation of the intracellular metabolic mechanisms and announced a new concept of anaesthetic preconditioning in coronary surgery. Large, randomized studies are needed to evaluate anaesthetic preconditioning and dependence of its efficiency on type and dose of volatile anaesthetics as well as the role of gene regulation in cardioprotection.

[Brugada syndrome--a brand new case].

BACKGROUND: Brugada syndrome (BS) is a disorder characterized by syncope or sudden death associated with one of several electrocardiographic (ECG) patterns characterized by incomplete right bundle branch block and ST elevation in the anterior precordial leads. Patients with BS are prone to develop ventricular tachyarrhythmias that may lead to syncope, cardiac arrest, or sudden cardiac death. CASE REPORT: A 58-year-old woman is the first described case of Brugada syndrome in Serbia with intermittent typical changes in basic electrocardiography (ECG): ST segment elevation in the precordial chest leads like dome or coved--major form or type I. For the last 27 years the patient had suffered of palpitations and dizziness, without syncopal events. Her sister had died suddenly during the night in sleep. During 24-hour Holter monitoring the patient had ventricular premature beats during the night with R/T phenomenon and during the recovery phase of exercise testing had rare premature ventricular beats as the consequence of parasympatethic stimulation. Late potentials were positive. Echocardiography revealed left ventricular ejection fraction of 60%. We performed coronary angiography and epicardial coronary arteries were without significant stenosis and structural heart disease was excluded. In the bigining of the electrophysiological study ECG was normal, and after administration of Propaphenon i.v. Brugada syndrome unmasked with appearance of type I ECG pattern. A programed ventricular stimulation induced non sustained ventricular tachycardia. One-chamber implantable cardioverter defibrillator was implanted and the patient was treated with a combination od amiodarone and metoprolol per os. After one-year folow-up, there were no episodes of ventricular tachycardia and ventricular fibrillation. CONCLUSION: Brugada syndrome is a myocardial disorder which prognosis and therapy are related to presence of ventricular fibrillation or ventricular tachycardia. Electrophysiologicaly induced malignant ventricular disorders class I are indication for implantation of cardioverter defibrilator, as also occurred in presented patient.

The fate of the radial artery conduit in coronary artery bypass grafting surgery.

Coronary artery bypass grafting (CABG) is the standard surgical procedure for the treatment of advanced coronary artery disease. CABG surgery has been demonstrated to improve symptoms and, in specific subgroups of patients, to prolong life. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. Impressive long-term disease-free patency rate of the left internal thoracic artery-left anterior descending coronary artery (LITA-LAD) graft, coupled with proven long-term survival benefits, has led to its becoming a 'golden standard' of CABG. Previous long-term studies have also shown unsatisfactory patency of saphenous vein grafts used for myocardial revascularization, compared with internal thoracic artery grafts. Thus, the use of arterial conduits has expanded beyond the internal thoracic arteries (ITAs) to include the right gastroepiploic artery, the inferior epigastric artery, and the radial artery. The assumption is that although the performance of one or two arterial ITA graft is superb, more arterial grafts should perform better in the long-term follow-up. Several studies concerning the use of the radial artery bypass grafts have documented excellent clinical results and satisfactory short-term as well as mid-term patency rates at restudy angiography, supporting its continued use as a bypass conduit. However, a note of caution concerning radial artery conduit patency rate have appeared in few recent reports. Thus, in this paper, we summarize the current evidence about the radial artery as a conduit in CABG surgery, with special emphasis on the clinical results.

Off-pump myocardial revascularization using the Octopus tissue stabilizer system.

Off-pump coronary artery bypass surgery (OPCAB) has changed the approach to contemporary coronary surgery. Development of new surgical devices and techniques has reduced morbidity and mortality during off-pump surgery. From March 2000-April 2002, a total of 136 patients underwent open heart surgery using off-pump technique and fast-track anesthesia at Dedinje Cardiovascular Institute. Octopus Medtronic coronary stabilizer was used for stabilization of targeted vessel. Arterial grafts were used 169 times and saphenous vein 69 times. Average number of anastomoses was 1,830,73 per patient. One patient (0.74%) died. Three patients (2.21%) underwent surgery revision due to postoperative bleeding and one (0.74%) because of graft dysfunction. Perioperative myocardial infarction was registered 2 times (1.47%), pneumothorax 3 times (2.21%), postoperative arrhythmias 11 times (8.09%), transitory ischemic attack once (0.74%) and deep wound infection once (0.74%). Twelve patients (8.82%) required prolonged inotropic support. Angiographies early revealed patent grafts in 8 patients (5.88%). OPCAB is a safe and effective alternative approach to coronary artery revascularization. Use of coronary stabilizer has improved the safety and quality of OPCAB surgery.