Learning Curve for No-Touch Vein Harvesting Technique in Off-Pump Coronary Artery Bypass Grafting.

INTRODUCTION: This study aims to evaluate the learning curve associated with the no-touch vein harvesting technique in off-pump coronary artery bypass grafting (CABG), highlighting its impact on surgical proficiency. METHODS: We employed logarithmic curve fitting to analyze the learning curves of 160 patients undergoing no-touch CABG, with a detailed retrospective examination of 89 patients who received three grafts using Cumulative Sum (CUSUM) analysis. Patients were categorized into two phases: the initial learning phase and the subsequent mastery phase, based on the chronological order of surgeries. We then compared perioperative outcomes between these phases. RESULTS: The learning curve for the no-touch vein harvesting technique was quantitatively established at 51 cases via CUSUM analysis, with supporting evidence from logarithmic curve fitting indicating a significant proficiency milestone. In the mastery phase, median operative times, aorta-saphenous vein graft (SVG) anastomosis, and SVG inspection durations were notably reduced (230 vs. 250 minutes, P = 0.002; 11.5 vs. 13.0 minutes, P = 0.025; 9.0 vs. 11.0 minutes, P = 0.002, respectively), alongside decreased initial 48-hour chest tube drainage, shorter postoperative hospital stays, and fewer incidences of delayed leg incision healing compared to the learning phase [312.6 (140.7) ml vs. 401.0 (233.5) ml, P = 0.029; 11.0 d vs. 12.0 d, P = 0.026; 15.7% vs. 2.6%, P = 0.043)]. CONCLUSION: Cardiac surgeons adopting the full-incision SVG harvesting method for no-touch CABG undergo a discernible learning curve before achieving early proficiency. It is crucial, especially during the initial learning phase, to focus on aorta-SVG anastomosis, the meticulous inspection for bleeding, and the management of wound complications to optimize patient outcomes.

Total arch replacement via single upper hemisternotomy approach for aortic aneurysm in syphilis: Case report.

RATIONALE: Syphilitic aortic aneurysm is a relatively rare type of cardiovascular syphilis. A small number of patients with syphilitic aortic aneurysms will be accompanied by aortic regurgitation and coronary stenosis. Apart from aortic rupture or dissection, syphilitic aortic aneurysm often causes associated vascular disorders, including left common carotid artery, innominate artery, and celiac artery stenosis or obstruction. PATIENT CONCERNS: In this case, we observed left common carotid artery occlusion based on both ultrasound and intraoperative exploration. For patients with syphilitic aortic aneurysm, the first choice is still sufficient antibiotic therapy. The surgical indications include symptom relief and prevention of aortic rupture or sudden death. DIAGNOSES: Aortic valve insufficiency, aortic aneurysm, and syphilis. INTERVENTIONS: Aortic valve replacement, aneurysmectomy and total arch replacement combined with frozen elephant trunk implantation via single upper hemisternotomy approach. OUTCOMES: The patient did not suffer reventilation and reoperation. No transient or permanent neurological dysfunction was observed in this patient. And no acute renal failure occurred. The patient was discharged on 43 days after the operation. LESSONS SUBSECTIONS: The upper hemisternotomy has the advantages of faster postoperative recovery, shorter ventilation time, shorter intensive care unit stay, less blood transfusion, and less incisional pain compared with the full sternotomy, which is one of the reasons why we chose this procedure for this patient.

Obesity and acute type A aortic dissection: unraveling surgical outcomes through the lens of the upper hemisternotomy approach.

Background: Acute type A aortic dissection (ATAAD) is a pressing cardiovascular emergency necessitating prompt surgical intervention. Obesity, a pervasive health concern, has been identified as a significant risk factor for ATAAD, introducing unique surgical challenges that can influence postoperative outcomes. This study aimed to investigate the outcomes of ATAAD surgery across various body mass index (BMI) categories, focusing on the implications of the upper hemisternotomy (UHS) approach. Methods: Between April 2017 and October 2023, 229 patients diagnosed with ATAAD underwent aortic arch intervention via UHS at the General Hospital of Northern Theater Command. Based on BMI (WS/T 428-2013), patients were categorized into normal weight, overweight, and obese. The primary outcomes included perioperative parameters, intraoperative details, and postoperative complications, with specific emphasis on hypoxemia, defined by the Berlin criteria as a PaO2/FiO2 ratio of ≤300 mmHg. Results: The average age of the cohort was 50.1 ± 11.2 years with a male predominance (174 males). Preoperatively, 49.0% presented with hypoxemia, with the Obese group exhibiting a significantly elevated rate (77.9%, P < 0.001). Postoperatively, while the Normal group demonstrated a lower thoracic drainage volume 24 h post-surgery [180.0 (140.0) ml; P < 0.001], the Obese group indicated prolonged durations for mechanical ventilation and ICU stay, without statistical significance. Unlike the Normal and Overweight groups, the Obese group showed no notable changes in pre- and postoperative PaO2/FiO2 ratio. No significant difference was observed in severe postoperative complications among the groups. Further ROC curve analysis identifies a BMI cutoff of 25.5 for predicting postoperative hypoxemia, with 76.3% sensitivity and 84.4% specificity. And multivariate analysis reveals BMI and preoperative hypoxemia as independent predictors of postoperative hypoxemia. Conclusion: Obesity, although presenting unique challenges in ATAAD interventions, does not necessarily portend adverse outcomes when managed with meticulous surgical planning and postoperative care. The study emphasizes the significance of individualized patient assessment and tailoring surgical strategies, suggesting the potential of UHS in addressing the surgical intricacies posed by obesity in ATAAD patients. Further research is warranted to consolidate these findings.

The Learning Curve of Total Arch Replacement via Single Upper Hemisternotomy Approach in Aortic Dissection.

Purpose: Upper hemisternotomy (UHS) has benefits over conventional full sternotomy because it ameliorates trauma during cardiac surgery. Owing to its challenging and technically demanding nature, this incision in acute type A aortic dissection (ATAAD) has rarely been reported. This study aimed to analyze the learning curve of total arch replacement (TAR) with moderate hypothermic circulatory arrest via a single UHS approach, which is necessary to guide the training of surgeons in adopting minimally invasive procedures. Patients and Methods: A total of 202 consecutive patients who were definitively diagnosed with ATAAD between July 2016 and June 2021 were enrolled in this retrospective analysis. Patients were divided into three groups based on cumulative sum plots for circulatory arrest time in chronological order. Perioperative characteristics were compared between the groups. Results: There was significant difference in the circulatory arrest time and cross-clamp time respectively among three groups (39.0 min vs 28.0 min vs 15.0 min, P < 0.001; 104.5 min vs 106.2 min vs 84.1 min, P < 0.001). The ventilation time and first 24-h chest tube drainage were statistically different among groups (35.5 h vs 24.0 h vs 19.0 h, P = 0.031; 220.0 mL vs 192.5 mL vs 125.5 mL, P = 0.043). No other clinical outcome was observed as significant difference. Conclusion: A cardiac surgeon can convert a conventional full sternotomy to a single UHS for TAR after experiencing a learning curve, to ensure patient safety. The mastery of this minimally invasive surgical technique may be beneficial for the prognosis of patients with ATAAD.

High level of intraoperative lactate might predict acute kidney injury in aortic arch surgery via minimally invasive approach in patients with type A dissection.

Background: A high incidence of acute kidney injury (AKI) has been recorded in total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation in patients with acute type A dissection (ATAAD) via median sternotomy approach with some risk factors. However, the independent risk factors for AKI via a minimally invasive approach have not yet been identified. Methods: A total of 207 patients with ATAAD were enrolled from January 2018 and November 2019 and were divided into AKI and non-AKI groups. The current surgical strategy was TAR combined with FET via a single upper hemisternotomy approach, a minimally invasive method. An increase in the serum creatinine (Cr) level to ≥2 times the baseline level 48 h post-surgery was defined as AKI. The morbidity of AKI was investigated with a step-by-step backward multivariate analysis of its independent risk factors and a receiver-operating characteristic curve analysis. Results: Postoperative AKI was observed in 39 (18.8%) patients, and the total hospital mortality was 8.7%. Univariate analysis found that preoperative Cr, weight, circulatory arrest time ≥60 min, intraoperative highest lactate (Lac), and intraoperative transfusion had significant differences between the two groups. However, multivariate step-by-step backward logistic regression analysis identified intraoperative highest Lac and transfusion as independent risk factors for postoperative AKI and intraoperative highest Lac was identified as the most critical independent risk factor estimated by the partial chi-square statistic minus the predicted degrees of freedom with 4.3 mmol/L as the optimal cut-off point for prediction for AKI. Conclusions: Intraoperative highest Lac and transfusion were independent risk factors for postoperative AKI, which led to high hospital mortality. Moreover, intraoperative highest Lac was the most critical independent risk factor and high level of intraoperative highest Lac (4.3 mmol/L) might predict for postoperative AKI.

Both J- and L-shaped upper hemisternotomy approaches are suitable for total arch replacement with frozen elephant trunk in patients with Type A dissection.

Background: Minimally invasive total arch replacement (TAR) with frozen elephant trunk (FET) implantation can be carried out through J-, L-, and inverted T-shaped upper ministernotomy. L- and inverted T-shaped upper ministernotomy are selected mostly for their better surgical view compared to J-shaped. However, few studies have paid attention to the difference in clinical effects between J- and L-shaped upper hemisternotomy in acute Type A aortic dissection (ATAAD). Materials and methods: We retrospectively analyzed 74 consecutive patients with ATAAD who underwent TAR with FET implantation between December 2019 and October 2020. Patients were divided into the L group (n = 31, L-shaped upper hemisternotomy) and the J group (n = 43, J-shaped upper hemisternotomy). Perioperative characteristics were recorded. Results: No significant difference was found in any of the pre-operative, post-operative, or follow-up variables between the two groups. However, the CPB establishment time in the J group was significantly shorter than that in the L group (65.0 ± 17.9 min vs. 77.9 ± 17.2 min, P < 0.05). Other intraoperative variables showed no significant difference. Conclusion: Total arch replacement with frozen elephant trunk implantation is feasible and can be carried out safely through J-shaped or L-shaped incision. A J-shaped incision might be beneficial for single incision, while an L-shaped incision might be beneficial if an extra incision is required to achieve better artery perfusion.

The Effect of Off-Pump Coronary Artery Bypass Grafting in Patients on Aspirin Therapy until Surgery Day.

Coronary artery bypass grafting (CABG) is widely used to treat coronary artery disease, and intraoperative and postoperative bleeding is one of the major factors affecting the efficacy and mortality of CABG. To overcome the adverse effects of extracorporeal circulation (CPB), nonextracorporeal coronary artery bypass grafting (OPCABG) has become the main modality of CABG but is still prone to thromboembolic events. Whether antiplatelet agents should be clinically applied before CABG, especially OPCABG, remains controversial. Aspirin is currently the most important perioperative oral antiplatelet agent for coronary artery bypass graft surgery. In this study, we evaluated the effect of continuing aspirin therapy before OPCABG and observed perioperative performance and physiological indicators to find evidence for continuing aspirin therapy before surgery in China. The study showed that preoperative aspirin application had a positive effect on enhancing early postoperative platelet inhibition without increasing the incidence of adverse effects such as cardiovascular events. This provides an important clinical reference for whether antiplatelet agents should be applied before CABG, especially OPCABG.

Mild Hypothermic Circulatory Arrest with Lower Body Perfusion for Total Arch Replacement Via Upper Hemisternotomy in Acute Type A Dissection.

BACKGROUND: Mild hypothermia circulatory arrest combined with lower body perfusion (LBP) might be beneficial for the recovery of patients with acute type A dissection. However, the safety of mild hypothermic circulatory arrest with LBP used in total arch replacement combined with frozen elephant trunk implantation (FET) via single upper hemisternotomy approach is ambiguous. METHODS: We retrospectively analyzed 70 consecutive patients with acute type A dissections who underwent total arch replacement combined with FET between April 2019 to December 2019. These individuals were divided into the moderate (MO) group (N = 39, surgery performed at moderate hypothermic circulatory arrest) and the mild (MI) group (N = 31, surgery conducted at mild hypothermic circulatory arrest with LBP). Perioperative characteristics were recorded. RESULTS: No significant difference in any of the pre- and intraoperative variables was observed between the two groups except for circulatory arrest time, which was significantly shorter in the MI group compared with the MO group [10 (8-11) min vs. 35 (31- 34) min, P = 0.000]. After operation, ventilation times [19 (16 - 24) h vs. 24 (17 - 43) h, P = 0.046] and ICU stay [41 (34 - 58) h vs. 54 (42 - 85) h, P = 0.002] were significantly shorter in the MI group compared with the MO group. CONCLUSIONS: Total arch replacement combined with FET at mild hypothermia circulatory arrest with lower body antegrade perfusion via single upper hemisternotomy approach is safe and feasible with significantly shorter time of circulatory arrest compared with no LBP.

Total Arch Replacement via Single Upper-Hemisternotomy Approach in Patients With Type A Dissection.

BACKGROUND: An upper hemisternotomy (UHS) tends to be performed for aortic valve replacement. However, the safety of UHS for total arch replacement combined with frozen elephant trunk implantation in patients with acute type A dissections is ambiguous. METHODS: We retrospectively analyzed 162 consecutive patients with acute type A dissections who underwent total arch replacement combined with frozen elephant trunk implantation between May 2016 and April 2018. A total of 153 patients enrolled were included, divided into the UHS group (n = 73, single upper hemisternotomy) and full sternotomy (FS) group (n = 80). Perioperative characteristics were recorded. RESULTS: There was no significant difference in any preoperative or intraoperative variables between groups. However, ventilation times (18 hours [range, 12-303 hours] versus 20.5 hours [range, 3-244 hours]; P = .002) were significantly shorter in the UHS group compared with the FS one. Results for the first 24 hours of chest tube drainage (160 mL [range, 70-700] versus 267.5 mL [range, 10-1,455 mL]; P = .001) were significantly less in the UHS group than the FS group. CONCLUSIONS: Total arch replacement combined with frozen elephant trunk implantation through a single upper-hemisternotomy approach in patients with acute type A dissections is a safe procedure that adds the benefit of a more cosmetic incision.