"H" graft from the right internal mammary artery to the left anterior descending coronary artery: an alternative strategy in reoperative grafting of the LAD territory.

Reoperative grafting of the left anterior descending (LAD) coronary artery or its diagonal branches can be accomplished through a left anterior small thoracotomy (LAST) on the beating heart using the left internal mammary artery (LIMA) as a conduit. Patients in whom the LIMA has been used previously, however, are generally excluded from this approach unless an alternative technique is utilized. We describe a new technique applicable to these patients that consists of grafting the LAD through a LAST approach and connecting the graft to the right internal mammary artery (RIMA).

Limited access left thoracotomy for reoperative coronary artery disease: on or off pump.

Between 1971 and 1988 left thoracotomy was performed on pump for selected reoperations. Since 1993, 92 patients were operated on with a limited approach and an increased number of cases were done off pump (70 patients). The purpose of this paper is to describe the transition of our operative techniques from on pump to off pump for reoperative coronary patients. From 1995 to 1999, 22 patients (Group 1) were operated on pump and 70 patients (Group II) off pump; 86 of 92 (93.5%) had reoperations. The demographic data were similar in these two groups regarding age, gender, ejection fraction, and total number of grafts performed. In this study 92 patients had a crude mortality of 4.3%. Limited access thoracotomy provides safer reoperation than previously (1971-1988) with an improved on or off pump (4.5% vs. 4.3%) mortality, compared to the on pump mortality of 10% between 1971-1988. Off-pump operations are performed with increasing frequency and with the same risk and less postoperative complications.

Pitfalls of undetected patent foramen ovale in off-pump cases.

We describe pitfalls of a hitherto undetected patent foramen ovale during the conduct of an off-bypass coronary revascularization. Manipulation of the heart resulted in right-to-left shunt and severe desaturation requiring institution of cardiopulmonary bypass to close the patent foramen ovale and complete the revascularization.

Myocardial release of non-transferrin-bound iron during cardio-pulmonary bypass surgery.

Myocardium reperfusion following coronary artery bypass grafting (CABG) may result in "reperfusion injury" by free radical generations. Since desferrioxamine administration attenuates this syndrome, non-transferrin-bound-iron (NTBI) released into the perfusing medium during CABG was implicated as a catalyst for oxygen radical formation. From 13 patients with "redo" CABG, specimens were collected from the coronary sinus (influx) and the aortic vent (efflux) after each distal coronary anastomosis. Specimens were subjected to sieving chromatography, and fractions were analyzed for total iron and NTBI using atomic absorption spectrometry (AAS). A statistically significant increase in NTBI was measured in influx (p = 0.002) and efflux samples (p = 0.023) collected after each graft. The combined amount of NTBI measured in these specimen was proportional to the CK-MB increase measured in the patients' sera on the day of surgery and the subsequent day. NTBI which accumulated in the circulatory bypass fluid during CABG may catalyze the generation of free radicals in the myocardium when body temperature is restored. This may aggravate myocardial damage as reflected by a post-surgical increase in CK-MB concentrations. Studies are in progress to develop new methods for the removal of NTBI during cardiac surgery. Tissue injury occurs with reperfusion during ischemia. This has been attributed to oxygen-derived free radicals that are generated by substances released from hypoxic areas (Kloner, Przyklenk et al., 1989; McCord, 1998). Reperfusion injury, i.e. the "reperfusion syndrome," occurs after coronary artery bypass grafting (CABG) when the ischemic myocardium is again provided with a supply of blood. Its most serious manifestations are arrhythmia and myocardial stunning (Ar"Rajab, Dawidson et al., 1996; Ferrari, Ceconi et al, 1996). The role of iron in reperfusion injury has been implicated by indirect evidence: during the reperfusion syndrome, the binding of iron with the chelator desferrioxamine (Ambrosio, Zweier et al., 1987; Bel, Martinod et al., 1996), or the administration of exogenous apo-transferrin, improved cardiac contractility and delayed manifestations of cardiac injury (Tiede, Sareen et al., 1990). Iron, as a transition metal, is able to catalyze free radical formation when released into the circulation from endogenous stores as non-transferrin-bound-iron (NTBI). This iron may be bound to small proteins or inorganic ligands (Halliwell and Gutteridge, 1984; Pollock and Campana, 1980; Zweier, 1992). A method for the measurement of NTBI was recently developed (Ambrus, Stadler et al., 1999). The purpose of this study was to explore whether a correlation exists among (a) the amount of NTBI released during CABG surgery, (b) the length of time of myocardial ischemia, and (c) the myocardial damage that occurs during cardiopulmonary bypass.

Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery without pump.

OBJECTIVE: To explore the feasibility to operate on the right coronary artery and its branches utilizing the right gastroepiploic artery (RGEA) without cardiopulmonary bypass (CPB). All cases were performed since May 1996. METHODS: A small mid-line incision including splitting of the lower sternum gave excellent exposure. The inferior surface of the heart was dissected to expose and stabilize the target vessel. The heart rate was controlled with a Diltiazem drip. CPB was not necessary in any case. The right coronary artery was bypassed in four patients, the posterior descending artery branch in five patients and the terminal circumflex of the left coronary artery in one patient. After grafting, patency of the anastomosis was demonstrated by Doppler echocardiogram. RESULTS: No patient had perioperative mortality or complications. No patient had recurrent angina. Color Doppler echocardiographic imaging studies before discharge confirmed patency of the graft in eight of ten cases. In two cases, the gastroepiploic artery could not be visualized. Angiographic visualization was positive in four out of five cases. CONCLUSIONS: The gastroepiploic artery is an excellent conduit for vascularization of the inferior aspect of the heart. The operation can be done using a minimally invasive technique and without the use of cardiopulmonary bypass. This approach seems especially applicable in selective reoperative cases.

Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery.

OBJECTIVE: The purpose of this study was to evaluate morbidity and mortality in reoperative coronary artery bypass surgery using the New York State database. METHODS: Patients undergoing reoperative coronary artery bypass between January-1995 and December 1996 were included. Patients were operated using cardiopulmonary bypass (CPB group, n = 184) or without cardiopulmonary bypass (non-CPB group, n = 105) by surgeon preference. Groups were compared for preoperative risk factors, postoperative mortality and major complications. RESULTS: Crude mortality was lower in the non-CPB group, despite a higher expected mortality, resulting in a risk-adjusted mortality of 1.3% versus 2.7% for the CPB group (NS). Of non-CPB patients, 91.4% were without complications, while only 72.1% of CPB patients (P < 0.0001) were complication-free. Major complications were significantly reduced in non-CPB patients compared to CPB patients: stroke 0% versus 3.8% (P < 0.04), cardiovascular complications 4.8% versus 15.8% (P < 0.005), other major complications 1.9% versus 10.4% (P < 0.007). Postoperative IABP support was needed in 1.9% of the non-CPB group patients and in 14.2% of the CPB group (P < 0.0007). CONCLUSIONS: The main object of reoperative CABG is to relieve symptoms, since the survival benefit of the procedure has not been demonstrated. Performance of reoperative coronary artery bypass surgery without cardiopulmonary bypass significantly reduces morbidity. We conclude that cardiopulmonary bypass should be avoided whenever possible in reoperative coronary bypass surgery.

Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB): a strategy for improving results in surgical revascularization.

BACKGROUND: Coronary artery bypass grafting (CABG) was performed on patients with cardiopulmonary bypass (CPB group) or without CPB (non-CPB group). A series of CABG patients, performed between January 1, 1995 and September 30, 1997 is included. METHODS: Data were collected and analyzed as determined by the New York State Department of Health. Preoperative comorbidity, postoperative morbidity and mortality were compared. There were 2869 patients in the CPB group and 505 patients in the non-CPB group. RESULTS: Demographics of the two groups were similar but preoperative risk factors were more common in patients undergoing CABG without CPB. Of the non-CPB patients, 31.9% had reoperations as compared to 8.5% in CPB patients (p = 0.00005). The presence of an extensively calcified aorta was more common in the non-CPB patients (5.9% vs. 2.8%, p = 0.0002). Immune deficiency was also more common in the non-CPB group (p = 0.001). Risk-adjusted mortality was similar in the two groups while major complications were much less common when CPB was not utilized. In CPB patients only 84.3% avoided major complications, while among non-CPB patients 90.1% were complication-free (p = 0.0008). CONCLUSIONS: CABG without CPB is an attractive method of surgical revascularization. Increasing age and preoperative comorbidity in patients referred for CABG dictate changes in surgical strategy, of which avoidance of CPB appears most beneficial.

Reoperations with the right gastroepiploic artery without cardiopulmonary bypass.

The right gastroepiploic artery (RGEA) has been utilized as the bypass conduit on the inferior surface of the heart with a minimally invasive approach. Fourteen patients had reoperative coronary bypass surgery for severely symptomatic single-vessel disease of the right coronary artery. All surgeries were performed since May 1996. A small mid-line incision including splitting of the lower sternum gave excellent exposure. The inferior surface of the heart was dissected to expose and stabilize the target vessel. The heart rate was controlled with a diltiazem drip. Cardiopulmonary bypass was not necessary in any case. The right coronary artery was bypassed in three patients, the posterior descending artery branch in ten patients, and the terminal circumflex of the left coronary artery in one. After grafting, patency of the anastomosis was demonstrated by Doppler echocardiogram. Two patients had left anterior descending artery (LAD) grafts with LIMA (left mammary artery) and RGEA grafts performed simultaneously with two port access incisions. No patient had perioperative mortality or complications. No patient had recurrent angina. Doppler color echocardiographic imaging studies before discharge confirmed patency of the graft in 13 of 14 cases. In one case, the gastroepiploic artery could not be visualized. Angiographic visualization was positive in seven cases; seven patients were not studied yet. The gastroepiploic artery is an excellent conduit for vascularization of the inferior aspect of the heart. The operation can be done with a minimally invasive technique and without the use of cardiopulmonary bypass. This approach seems especially applicable in selective reoperative cases.

Coronary artery bypass grafting without cardiopulmonary bypass--an attractive alternative in high risk patients.

OBJECTIVE: This study compares preoperative risk factors, estimated, observed, and risk adjusted mortality, and postoperative complications in patients undergoing coronary artery bypass grafting. Patients were divided in two groups depending on operative method: Group A patients had coronary artery bypass grafting using cardiopulmonary bypass. In group B cardiopulmonary bypass was not utilized. Patients operated on between January 1 1995 and August 31 1996 were compared. Group A consisted of 1829 patients and Group B 172. METHODS: Patients were selected to undergo coronary artery bypass grafting without the use of cardiopulmonary bypass either because the surgeon felt that there were contraindications to--or no need for the heart-lung machine. The decision to avoid the use of cardiopulmonary bypass was taken pre-operatively by the individual surgeon. Median sternotomy, formal left thoracotomy or left anterior small thoracotomy were used. The data was collected and validated by the hospital's professional data collectors. Data-analysis was performed using the NY-state database. RESULTS: Previous heart surgery and extensively calcified ascending aorta were significantly more common in Group B as was estimated and observed mortality. This resulted in identical risk-adjusted mortality of 2.8%. When reoperations were reviewed separately risk adjusted mortality was lower in Group B (2.1 versus 3.1%) but this difference was not statistically significant. Cardiovascular-and other-complications were higher in group A patients. In reoperative patients this difference was significant (P = 0.05). The need for postoperative mechanical assistance was also reduced (Group A: 14.9% versus Group B: 1.3% P = 0.01). CONCLUSION: We conclude that coronary artery bypass surgery can be done safely in selected patients without cardiopulmonary bypass. Mortality is unchanged and complications are less frequent. Cost and hospital utilization are decreased. The greatest benefit is observed in reoperations.

Pacemaker lead placement via a small cephalic vein.

The development of implantable defibrillators with single lead systems has necessitated the need for larger transvenous electrodes. This article describes a modified Seldinger technique that can be used when the cephalic vein is too small to allow passage of these larger leads. When successful, the procedure eliminates the need for direct needle cannulation of the subclavian vein and the accompanying risk of pneumothorax.

Comparison of long-term patency of "horseshoe" saphenous vein grafts with and without valves.

OBJECTIVE: The paper analyzes the long-term patency of valveless and valvular limbs of reversed saphenous veins. METHODS: Between 1983 and 1988, 335 patients underwent isolated coronary artery bypass grafting (CABG) with 1,329 grafts. Eighty-three patients had follow-up angiography over 8-12 years. The side-to-side saphenous vein to aortic "horseshoe" anastomosis was created just before the first valve from the ankle (naturally a valveless portion). The valveless (ankle end) was depicted in every case. These patients with angiography were similar to 252 patients without angiography in terms of age, gender, number of grafts, diseases vessels, single (A) and sequential (B) grafts and actuarial survival. In the 83 patients, graft patency was 75%. Overall patency was the same in B versus A grafts (76% versus 74.6%); valveless patency (78.7%) was slightly better than valvular patency (73.3%). RESULTS: In patients with B grafts (88.6%) valveless patency was significantly better than valvular patency (71.9%) (P < 0.02). The patency of B-valveless to the left coronary bed was also better, (86.8% versus B-valvular 70.5%, P < 0.04). Attrition of the B-valveless and B-valvular grafts was similar up to 8 years, but by the 12th year it had become significantly different (P < 0.05). The 12-year actuarial survival rate of the patients was 87.7%. CONCLUSIONS: We recommended the use of valveless vein segments when possible.

Excision of papillary fibroelastoma arising from the septal leaflet of the tricuspid valve.

A case of a papillary fibroelastoma (PFE) arising from the tricuspid valve was reported. It was incidentally detected by two-dimensional transthoracic echocardiography. Prior to 1977, these tumors were exclusively found at postmortem examination. This is only the fourth reported case of a tricuspid valve PFE found by echocardiography, treated by excision, and with tricuspid valvuloplasty preserving the native valve.

Arterial venous bridge on cardiopulmonary bypass.

An arterial venous bridge has been routinely interspaced between the arterial and the venous lines of the pump circuit during cardiopulmonary bypass at our institution for over 25 years. We have found it to be extremely useful in certain situations: (1) prepump priming and equipment failure; (2) recirculation of pump prime for fast cooling or rewarming; (3) shunting following valve surgery; (4) venous transfusion, retrograde cerebral perfusion during circulatory arrest, rapid initiation of retrograde perfusion in case of massive air embolism; and (5) ultrafiltration in patients with renal insufficiency.

Combined aortic valve replacement and closure of patent ductus arteriosus in the elderly.

Two cases of patent ductus arteriosus (PDA) and aortic stenosis are presented. Both were diagnosed at routine cardiac catheterization and significant aortic gradient was concomitantly encountered. The first patient had subacute bacterial endocarditis due to B. cereus infection. Eventually it was proven to be localized on the PDA on the pulmonary artery side. Both patients underwent closure of PDA through endopulmonary closure and aortic valve replacement. Postoperative courses were uneventful. These cases demonstrated the technically easy closure of the PDA in the elderly. The literature has documented only six cases including our two cases.

Comparison of cold versus warm cardioplegia. Crystalloid antegrade or retrograde blood?

BACKGROUND: To evaluate the efficacy of warm versus cold and antegrade versus retrograde cardioplegia, 163 patients were randomized in sequence in three groups and underwent isolated coronary artery bypasses (mean, 4 grafts/patients) alternating in sequence. METHODS AND RESULTS: The demographic profiles were identical. Cold crystalloid cardioplegia (group 1) was delivered through the aortic root intermittently. The warm retrograde (group 2) was started antegrade with high potassium solution until the heart stopped. It was continued with retrograde coronary sinus perfusion, 100 mL/min of warm blood. Cold retrograde blood cardioplegia (4:1) (group 3) was started antegrade and continued retrograde through the coronary sinus. The heart temperature was kept at 10 degrees to 15 degrees C. Patients were evaluated intraoperatively and postoperatively for (1) supraventricular tachycardia, (2) ECG changes, (3) lactate dehydrogenase and total CPK and isoenzyme (MB) studies, and (4) hemodynamic studies in the intensive care unit. Warm retrograde and cold retrograde patients had sampling of the ascending aorta (antegrade) and the coronary sinus (retrograde) measuring pH, A-VO2 differences, and CK enzyme leak. RESULTS: The incidence of supraventricular tachycardia was 29% in group 2, 22% in group 1, 18% in group 3; not significant (NS). CPK isoenzyme MB fraction showed identical levels (NS). The warm heart consumed 1.3 to 1.6 mL O2/100 mL flow, while the cold group 3 showed 0.5 to 0.6 mL O2/100 mL flow (P < .001). Cold crystalloid cardioplegia (group 1) was similar to group 3 (0.3 mL O2/100 mL). All three groups were similar hemodynamically (cardiac output, cardiac index, left ventricular stroke work index). Two of 163 patients died in group 2. Four sustained stroke, three in group 2, one with a fatal outcome. CONCLUSIONS: Continuous warm cardioplegia (group 2) did not provide better myocardial protection despite that no CK-MB isoenzyme leak was demonstrated intraoperatively. Intermittent cold crystalloid cardioplegia and cold retrograde provided a clearer operative field and motionless heart. As long as O2 was adequately supplied, under 90 minutes' cross-clamp time, cold crystalloid cardioplegia and cold retrograde blood cardioplegia is safe under hypothermic conditions, whereas warm cardioplegia requires continuous uninterrupted technique with oxygen delivery.

Intramyocardial calcification in the elderly. A diagnostic and therapeutic puzzle.

A 70-year-old woman presented with anular and progressive intramyocardial calcification within a five-year period. She had become increasingly symptomatic with mitral regurgitation and coronary insufficiency during the same period. The subvalvular (mitral) calcified intramyocardial mass was found to be "grumous atherosclerosis." This was obliterated while the mitral valve was replaced with a prosthetic valve and the coronary arteries were bypassed x3. She is surviving and well four years postoperatively.

Left thoracotomy reoperation for coronary artery disease.

Twenty patients underwent reoperative coronary artery bypass grafting (CABG) through a left thoracotomy since 1971. This was their second CABG in 16 patients, third in three patients and fourth in one patient. Surgery was performed from 1 to 16 years following the initial procedure. Demographic data showed no significant variation from patients undergoing standard reoperative CAGB in this institution. Ejection fraction varied between 30% and 73%. Cardiopulmonary bypass technic has gradually developed since 1971, using the left femoral artery and vein. For venous cannulation a 50-cm long catheter was positioned in the right atrium. Monitoring included pulmonary artery catheter with oximetry. Fibrillatory arrest of the heart was utilized with 18-33 degrees C core cooling cardioplegia. The left internal mammary artery (6) and reverse saphenous veins (44) were used for an average of 2.5 grafts per patient. The proximal anastomosis was placed on the descending thoracic aorta or the left subclavian artery. There were two early and no late deaths. Sixteen patients were restudied before discharge from the hospital with an early graft patency rate of 98% (41/42). The left thoracotomy approach may be preferable in selected cases of redo CABG. The danger of damage to the heart and patent grafts is greatly reduced.

Pulmonary resection combined with cardiac operations.

Surgical management of patients with concomitant critical cardiac disease and resectable lung lesions is controversial. During a 7-year period (1982 to 1988), 21 patients underwent combined cardiac and pulmonary operations. Patients had cardiac symptoms only; the lung lesions were found on preoperative chest roentgenograms. The pathological diagnosis was established in only 2 of the patients before operation. All underwent concurrent pulmonary resection during cardiac operations requiring extracorporeal circulation. The pulmonary operations included 17 wedge resections and four lobectomies. The final diagnoses in 8 patients with stage I non-small cell lung cancer included epidermoid carcinoma (4), adenocarcinoma (3), and bronchoalveolar carcinoma (1). Postoperatively, 1 patient required a permanent pacemaker and 1 patient died. The actuarial survival at 5 years for all patients who underwent combined procedures was 95%. The 5-year survival for the 8 patients with lung cancer was 88% compared with 100% for those with benign pulmonary pathology (p = 0.172). This experience suggests that combining pulmonary resection with cardiac operations is safe and offers a favorable prognosis to a select group of patients.

Intracavitary melanoma of the left atrium.

A 32-year-old man was seen with shortness of breath and increasing fatigue. Echocardiography revealed an intracavitary mass occupying the entire left atrium. The lesion was resected using cardiopulmonary bypass and found to be a large malignant melanoma. This case represents the rare occasion in which antemortem diagnosis of malignant melanoma within left atrium permitted successful palliative surgical resection. The patient is alive and active 6 months after operation.