Rescue percutaneous coronary intervention for graft failure immediately after coronary artery bypass grafting: case report and review of literature.

Perioperative graft failure remains a significant problem and carries a very high morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). Different therapeutic options are available for the clinician to manage this complication. These include direct reoperation, balloon angioplasty, angioplasty along with stenting, intra-aortic balloon pumping, and conservative medical management. Immediate percutaneous coronary intervention has been reported to be a viable alternative to emergent redo CABG in these patients. Herein, we report an additional case of early graft failure immediately following CABG and review the existing literature.

Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis.

OBJECTIVE: Stent grafting has become the first-line approach to traumatic thoracic aortic transections (TTAT) in some trauma centers due to a perceived decrease in morbidity and mortality compared with standard open repair. We reviewed contemporary outcomes of patients undergoing endovascular repair of TTAT (endoTTAT) and those undergoing open repair (openTTAT) to determine if current reported results support first-line use of endoTTAT. METHOD: Retrospective, nonrandomized studies published in English (>5 cases/report) involving TTAT listed in PubMed between 2001 and 2006 were systematically reviewed. Periprocedural outcomes between endoTTAT and openTTAT were analyzed. Mean follow-up was 22.9 months for endoTTAT (reported for 22 of 28 studies) and 48.6 months for openTTAT (reported for 5 of 12 studies). For statistical analysis, t tests were used. RESULTS: We analyzed 33 articles reporting 699 procedures in which 370 patients treated with endoTTAT and 329 patients managed with openTTAT. No statistical differences were found between patient groups in mean age (41.3 vs 38.8 years, P < .10), injury severity score (39.8 vs 36.0, P < .10), or technical success rates of the procedure (96.5% vs 98.5%, P = .58). In contrast, mortality was significantly lower in the endoTTAT group (7.6% vs 15.2%, P = .0076) as were rates of paraplegia (0% vs 5.6%, P < .0001) and stroke (0.85% vs 5.3%, P = .0028). The most common procedure-related complications for each technique were iliac artery injury during endoTTAT and recurrent laryngeal nerve injury after openTTAT. CONCLUSIONS: To our knowledge, no large multicenter prospective randomized trial comparing endoTTAT and openTTAT has been published in the literature. This meta-analysis of pooled data serves as a surrogate, demonstrating a significant reduction in mortality, paraplegia, and stroke rates in patients who undergo endoTTAT; however, the long-term durability of endoTTAT remains in question.

Case report of cardiac arrest, abdominal compartment syndrome, and thoracic aortic injury with endovascular repair of thoracic aortic tear.

The introduction of thoracic endografts has revolutionized the management of thoracic aortic disease. Currently, endografts are not FDA-approved for treating thoracic aortic injury (TAI). We report a case of TAI who presented in hemorrhagic shock and preoperative cardiac arrest who was successfully treated with large volume resuscitation, closed chest cardiac massage, exploratory laparotomy, and thoracic endografting.

Endovascular repair of thoracic aortic tears.

BACKGROUND: Standard treatment of traumatic thoracic aortic transection (TTAT) is open repair by left thoracotomy with or without the use of partial cardiopulmonary bypass. However, open repair is associated with high rates of morbidity and mortality, particularly in multiply injured trauma patients. We reviewed our experiences of endovascular repair of acute TTAT. METHODS: Between February 2001 and February 2006, 30 patients (male 24, female 6, mean age 43 years) who had sustained severe blunt trauma with multiple injuries (mean injury severity score = 42) underwent endovascular repair for TTAT. Devices used included commercially available proximal abdominal aortic extension cuffs and thoracic stent-grafts. Either low dose or no systemic heparin was used. Arterial access was obtained by femoral-iliac cutdown (n = 19) or completely percutaneous through the femoral artery (n = 11). Mean follow-up was 11.6 months (range, 1 to 48 months). RESULTS: Technically success was achieved in 100% of patients, as determined by angiographic and computed tomographic (CT) scan exclusion of TTAT. Mean operating time was 132 minutes. Mean blood loss was 300 cm3. Three patients had complications: 1 iliac artery rupture, 1 cerebellar stroke, and 1 partial stent collapse. There were 2 perioperative deaths. There were no instances of procedure-related paralysis. Clinical and CT follow-up did not reveal evidence of endoleak, stent migration, or late pseudoaneurysm formation. CONCLUSIONS: The adaptation of commercially available stent-graft devices to treat TTAT is technically feasible, and can be performed with low rates of morbidity and mortality. The long-term durability of endovascular repair of TTAT remains unknown, but early and midterm results appear promising.

Off-pump coronary artery grafting in patients with left main coronary artery disease.

BACKGROUND: Left main coronary artery disease (LMCD) is considered a relative contraindication to off-pump coronary artery bypass (OPCAB) grafting. This study evaluates the safety and feasibility of OPCAB in these patients compared to an on-pump group (cardiopulmonary bypass, CPB) with LMCD. METHODS: Between January 2000 and July 2002, 95 patients with left main coronary artery stenosis >50% underwent coronary revascularization. Seventy-three unselected patients underwent OPCAB and 22 underwent revascularization using CPB. The techniques used for OPCAB included the use of deep traction sutures in the posterior pericardium and stabilizers to expose the distal coronary targets. Intraluminal coronary shunts were routinely used during construction of the anastomoses. Variables were analyzed using a Student's paired t-test with statistical significance defined as p < 0.05. RESULTS: The mean age in the OPCAB group was 59.9 years and the CPB group 61.8 years (p = 0.54). There were 56 males (77%) in the OPCAB and 18 (82%) in the CPB groups. Mean preoperative left ventricular ejection fraction (LVEF) was 40.3% in OPCAB and 47.3% in CPB (p = 0.015). Average number of grafts was 3.1 in OPCAB and 4.1 in CPB (p = 0.0038). There were no conversions to CPB in those patients initially chosen to undergo OPCAB. There were no early deaths in OPCAB. There was one death in CPB. Mean hospital length of stay was 6.9 days for OPCAB and 9.1 for CPB (p = 0.0159). CONCLUSIONS: Patients with LMCD can undergo OPCAB grafting safely and effectively despite reduced LVEF. LMCD should no longer be seen as a contraindication to perform OPCAB grafting.

The history and development of direct coronary surgery without cardiopulmonary bypass.

The history of direct myocardial revascularization without cardiopulmonary bypass dates to 1961 in the dawn of coronary artery surgery. With the introduction and development of techniques of extracorporeal circulation around the same time, beating heart surgery was largely abandoned. Over the subsequent decades, cardiopulmonary bypass and electromechanical cardioplegic arrest became popular as means of revascularization in a bloodless and motionless field. While coronary artery surgery on the arrested heart remained undisputed for decades, myocardial revascularization on the beating heart was pursued by a few pioneering surgeons around the world, based on the belief that coronary revascularization could be performed equally well without the detrimental effects of cardiopulmonary bypass and electromechanical arrest. Various concepts and techniques developed during the 1980s by these pioneers enabled minimally invasive coronary surgery to be performed in the early 1990s. This break from the mainstream allowed selective myocardial revascularization using a minimal incision and no cardiopulmonary bypass to develop and constructed a base for future extensive revascularizations off-pump. With the subsequent explosion of new techniques for coronary exposure and myocardial stabilization, complete revascularization without cardiopulmonary bypass became possible with consistent results. Emerging from the preview of only a few surgeons just a decade ago, off-pump surgery is currently one of the accepted modalities for complete myocardial revascularization worldwide. This paradigm shift in the approach to myocardial revascularization has led to exiting new future possibilities, such as beating heart totally endoscopic coronary artery surgery.

Beating-heart valve surgery in patients with renal failure requiring hemodialysis.

BACKGROUND AND AIM OF THE STUDY: The safety and efficacy of beating-heart valve surgery as a myocardial protection strategy was evaluated in patients with renal failure requiring hemodialysis. METHODS: This was a retrospective review of nine patients (four males, five females; mean age 46.7 years; mean duration of hemodialysis 47 +/- 49 months) who underwent beating-heart valve surgery at the present authors' institution between April 2000 and September 2002. RESULTS: The mean cardiopulmonary bypass time was 77.2 +/- 8 min. Perioperatively, two patients died (one from sepsis; one from complication of anticoagulation). There were no deaths in the follow up since discharge, with average follow up 18.3 months (range: 9-27 months). Other complications included reintubation for <24 h (one case), AV graft thrombosis (one patient) and stroke (one patient, as mentioned above). There were no new cardiac (including arrhythmia and low cardiac output syndrome) or metabolic complications (including hyperkalemia and fluid overload). CONCLUSION: This is the first report of beating-heart valve surgery using simultaneous antegrade and retrograde perfusion with normothermic blood. Despite being small in size, the study demonstrated the safety of this approach in a high-risk population with renal failure requiring hemodialysis. The results suggested a low incidence of complications, and short ICU and hospital stays.

Redo-OPCAB via left thoracotomy using symmetry aortic connector system: a report of two cases.

Left thoracotomy is an established approach for redo coronary artery bypass grafting (CABG). This approach has also been successfully used in off-pump coronary artery bypass (OPCAB). Traditionally, the grafts have been anastomosed proximally to the descending thoracic aorta or the left subclavian artery. Recently, proximal connectors have been introduced by various manufacturers for use on ascending aorta during primary CABG and OPCAB. One such device is the Symmetry aortic connector system (St. Jude Medical, Minneapolis, MN). These devices have obviated the need for partial occluding clamps for the construction of the proximal anastomoses and hence are extremely useful when the aorta is heavily calcified. We used this device successfully in two patients undergoing redo-OPCAB, where the proximal anastomosis was constructed on the descending aorta. In so doing, we also used the shortest possible length of vein graft since the descending aorta at that level was much closer than the left subclavian artery. This can be an additional factor in redo-operations where the availability of vein can be an issue.

Initial experience with sutureless proximal anastomoses performed with a mechanical connector leading to clampless off-pump coronary artery bypass surgery.

BACKGROUND: We report our early experience with the Symmetry Aortic Connector (St. Jude Medical, St. Paul, MN) used for sutureless proximal aortosaphenous vein graft anastomoses without any cross clamp during coronary bypass procedures. METHODS: Between November 2001 and August 2002, 206 saphenous vein to aorta proximal anastomoses were created in 132 patients using the Symmetry device. All procedures were performed as part of off-pump coronary artery bypass surgery without any aortic clamping. Intraoperative variables and postoperative data were collected and analyzed retrospectively. RESULTS: All 206 anastomoses (100%) were successfully completed with the connector. Severe atherosclerotic disease of the aorta was documented in 16 patients (12%). Four anastomoses (2%) required additional suture placement. Predeployment problems occurred with 3 grafts (2.5%) during loading of the connector. Average number of distal bypasses was 3.2 per patient. One patient (0.7%) required reoperation for bleeding from a proximal anastomosis. Six patients (4.5%) had perioperative myocardial infarction documented by electrocardiographic changes. Thirty-day operative mortality was 3% (4 patients). Intraoperative transit time flow measurement was performed in all cases (100%). Postoperative angiography in 43 patients at a median 3 months postoperatively revealed occlusion of 9 of the 81 saphenous vein grafts (11%). CONCLUSIONS: The initial experience with a proximal saphenous vein graft to aorta anastomosis using the Symmetry connector demonstrates safety and ease of use. There is however some concern with early graft closure. A prospective randomized study is needed to clarify these concerns.

Novel use of an FDA-approved BiVAD for total cardiopulmonary support.

We describe the use of an Abiomed BVS 5000i with an oxygenator spliced into the right side for total cardiopulmonary support after orthotopic heart transplantation. As compared to ECMO, we believe that the mechanical ventricular unloading seen with this type of assist device increases the likelihood of myocardial recovery. This report demonstrates that even with an in-line oxygenator, adequate flow can be delivered to both the RVAD and LVAD, providing complete cardiopulmonary support.

Factors affecting late survival after surgical remodeling of left ventricular aneurysms.

OBJECTIVES: Surgical remodeling of the left ventricle has involved various techniques of volume reduction. This study evaluates factors that influence long-term survival results with 3 operative methods. METHODS: From 1979 to 2000, 157 patients (134 men, mean age 61 years) underwent operations for class III or IV congestive heart failure, angina, ventricular tachyarrhythmia, and sudden death after anteroseptal myocardial infarction. The preoperative ejection fraction was 28% +/- 0.9% (mean +/- standard error), and the pulmonary artery occlusive pressure was 15 +/- 0.07 mm Hg. Cardiogenic shock was present in 26 patients (16%), and an intra-aortic balloon pump was used in 48 patients (30%). The type of procedure depended on the extent of endocardial disease and was aimed at maintaining the ellipsoid shape of the left ventricle cavity. In group I patients (n = 65), radical aneurysm resection and linear closure were performed. In group II patients (n = 70), septal dyskinesis was reinforced with a patch (septoplasty). In group III patients (n = 22), ventriculotomy closure was performed with an intracavitary oval patch. RESULTS: Hospital mortality was 16% (25/157) and was similar among the groups. Actuarial survival up to 18 years was better with a preoperative ejection fraction of 26% or greater (P =.004) and a pulmonary artery occlusive pressure of 17 mm Hg or less (P =.05). Survival was worse in patients who had intra-aortic balloon pump support (P =.03). Five-year survival for all patients in group III was higher than for patients in group II (67% vs 47%, P =.04). CONCLUSIONS: Factors that improved long-term survival after left ventricular surgical remodeling were intraventricular patch repair, preoperative ejection fraction of 26% or greater, and pulmonary artery occlusive pressure of 17 mm Hg or less without the need for balloon pump assist.