Case-matched comparison of early and long-term outcomes of everted cervical vein and saphenous vein carotid patch angioplasty.

OBJECTIVES: To compare outcomes after carotid endarterectomy (CEA) with saphenous vein patch closure (SV), with cervical vein (external jugular and common facial) patch closure (CV). DESIGN: A total of 322 cases of CEA was achieved consecutively by using venous patch angioplasty. Propensity scores were calculated followed by a one-to-one basis case-matching. MATERIALS: This resulted into 90 SV and 90 CV matched cases. METHODS: The primary endpoint was the incidence of ipsilateral stroke and transient ischaemic attack at any time during follow-up. RESULTS: Ten-year freedom from stroke was 94.1% ± 3.5% for the SV group and 90.5% ± 4.2% for the CV group (log rank P = 0.230). Ten-year freedom from ipsilateral neurological events (stroke and transient ischaemic attack) was 93.5% ± 3.3% for SV group and 92.4% ± 3.0% for the CV group (log rank P = 0.403). Ten-year freedom from ≥75% stenosis/occlusion was 93.1 ± 4.8% for the SV group and 89.9 ± 6.0% for the CV group (log rank P = 0.481). CONCLUSIONS: CV is a good alternative to SV patching, particularly when the SV needs to be preserved for further use or is unsuitable.

Does a concomitant Cox-maze procedure improve survival in atrial fibrillation?

In this review paper, the authors briefly describe the pathophysiology of atrial fibrillation. The original technique to restore sinus rhythm is cited, with its subsequent technical variations. A literature review summarizes the outcome of patients who benefited from the Cox-MAZE procedure.

Quadricuspid aortic valve: a rare etiology of aortic regurgitation.

Quadricuspid aortic valve is a rare cause of aortic insufficiency. We report two unusual cases of this valvular pathology associated with a dilatation of the aortic root. The mechanism leading to this valve incompetence is incompletely understood and is discussed in regard to these cases.

Emergency hepato-renal artery bypass using a PTFE graft.

A 51-year-old patient suffering from Buerger's disease with bilateral lower limb amputation and Leriche syndrome presented with uncontrollable hypertension and renal failure caused by right renal artery subocclusive stenosis associated with an occluded left renal artery and atrophic kidney. He underwent a right hepato-renal bypass grafting using an externally supported polytetrafluorethylene (PTFE) graft. Renal function improved markedly and hypertension could be controlled by standard antihypertensive treatment. Normal right renal function was maintained at one-year follow-up.

Hook phlebectomy versus transilluminated powered phlebectomy for varicose vein surgery: early results.

OBJECTIVES: to compare Transilluminated Powered Phlebectomy (TIPP) (TriVex System) with Muller's hook phlebectomy. MATERIALS AND METHODS: between January and April 2001, 40 patients (group 1) undergoing TIPP were non-randomly compared to 40 patients undergoing Muller's hook phlebectomy (group 2) in the course of conventional vein stripping and perforator ligation. All patients had at least C2 CEAP disease. RESULTS: hospital stay averaged 2 days (range 1-3 days; median 2 days) and was similar for the two groups. TIPP took significantly longer (56+/-12 vs 45+/-10 min, p<0.001) but was associated with significantly fewer incisions (6 [2-8] vs 8 [4-21], p<0.001). The mean pain score (out of 10) at 2 and 7 days and 6 weeks was 5, 2 and zero after TIPP and 4, 2 and zero after hook phlebectomy. The incidence of postoperative haematoma formation was significantly higher after TIPP (45 vs 25%, p=0.06), especially in the calf region (25 vs 2.5%,p =0.003). CONCLUSION: TIPP was slower (although speed increased with practice) associated with more haematoma (although this reduced with practice) and fewer incisions. In other respects (pain, cosmetic satisfaction, other complications, residual varices) it was not significantly different from hook phlebectomy. Greater clinical experience with the technique and randomized studies are required to determine whether TIPP is a valuable addition to our armamentarium.

Scheduling of elective surgical cases within allocated block-times: can the future be drawn from the experience of the past?

UNLABELLED: We determined a strategy to regulate the elective occupation of operating rooms; it was based on the determination of a median operating room occupation time, per procedure and per operator. METHODS: Median occupation times were determined from a retrospective analysis of 12 consecutive months of operating activity (966 patients). These data were prospectively used in surgical planning, with a daily occupation limit set at 10 hours. After four months collecting data, daily recorded (ROT) and predicted (POT) occupation times were compared. The surgical activity during that test period (group A) was compared to the activity of the same period in the previous year (group B) and the evolution of the waiting lists for surgery were analysed for each of the operators. RESULTS: At the end of the four-month observation period, 317 surgical cases spread over 105 operating days were recorded. The correlation between ROT and POT was strong (r = 0.911, p < 0.001). The relative error in this prediction was 13 +/- 11 min. In comparison with group B, group A was characterized by a significant reduction in occurrence (p = 0.015) and duration (p = 0.007) of time limit overruns and in variability of daily occupation time (p < 0.001). The waiting list was reduced for all operators at the end of the test period. CONCLUSION: Determination of individualized median occupation times, associated with definition of a daily limit, resulted in reduction of time overruns and delays before surgery.

Beating heart surgery using the Octopus tissue stabilizers: initial experience including triple vessel disease and high-risk patients.

OBJECTIVE: The aim of this study was to evaluate initial results in beating heart coronary artery bypass grafting performed on patients with multivessel disease, using suction-based tissue stabilizers. METHODS: Forty patients (mean age 65.5 years, range 39-83) underwent beating heart coronary bypass by median sternotomy, with the use of the Octopus 1 (n = 27) and Octopus 2 (n = 13) devices. Twenty patients had unstable angina, four had pulmonary oedema, and four required preoperative intra-aortic balloon counterpulsation. Five interventions were repeat procedures. Mean ejection fraction was 54.4%(range 20-82%). Eighteen patients had triple-vessel disease, 18 patients had double-vessel disease and > 50% left main stem stenosis was present in six patients (isolated or in association). The average number of distal anastomoses was 2.5 (range 1-5, total 101). A mean of 1.5 (range 1-3) anastomoses was achieved with arterial grafts (45 mammary and 12 gastroepiploic arteries). RESULTS: Immediate graft patency was evaluated by Doppler flowmeter and five anastomoses were successfully corrected, based on an occlusion pattern. The perioperative myocardial infarction rate was zero. Transient episodes of supraventricular arrhythmias were detected in 19 patients. The administration of dobutamine at an inotropic concentration > 5 gamma-1 kg-1 min-1 was required in one patient. There were two in-hospital deaths (one non-cardiac-related). Overall survival and cardiac event-free rate at 20 months were 92.4% +/- 4.2% and 81.8% +/- 11.6%, respectively. CONCLUSIONS: Satisfactory results can be achieved in multivessel disease high-risk patients with beating heart coronary bypass surgery.

Six hundred consecutive carotid endarterectomies with temporary shunt and vein patch angioplasty: early and long-term results.

PURPOSE: This retrospective study evaluates the long-term clinical outcome and the survival of 600 consecutive carotid endarterectomies performed with a temporary shunt. All arteriotomies were closed by vein patch angioplasty. MATERIALS AND METHODS: Between November 1989 and November 1998, 600 isolated carotid endarterectomies (CEA) were performed in 540 patients by a uniform surgical technique at the University Clinic of Mont-Godinne. An intraluminal shunt and patch closure were systematically used. The mean age was 68 yr (ranging from 41 to 91 yr), 400 patients were men. The risk factors included hypertension in 73%, smoking history in 60%, coronary artery disease in 51% and hyperlipidemia in 35%. The indications were asymptomatic stenosis in 47%, transient ischemic attack in 40%, vertebrobasilar symptoms in 7% and stroke in 6%. EARLY RESULTS: The combined 30-day stroke and death rate was 0.9%. There were four deaths. The stroke and TIAs rates were 0.2% and 1.5% respectively. The incidence of early carotid occlusion was 0.5%. Cranial or cervical nerve dysfunction was identified in 6.3%. LATE RESULTS: The median follow-up was 49 months with a range of 2-124 months. Cumulative survival rates at 5 and 10 yr were 92+/-1% and 89+/-2% respectively. Thirty-two patients died during long-term follow-up; the death was stroke-related in only three patients. CONCLUSION: Carotid endarterectomy using an intraluminal shunt and vein patch closure is a safe and effective procedure associated with low morbidity and mortality rates at short and long-term follow-up.

Effective prevention of atrial fibrillation by continuous atrial overdrive pacing after coronary artery bypass surgery.

OBJECTIVES: The present study was aimed to evaluate the efficacy of a specific algorithm with continuous atrial dynamic overdrive pacing to prevent atrial fibrillation (AF) after coronary artery bypass graft (CABG) surgery. BACKGROUND: Atrial fibrillation occurs in 30% to 40% of patients after cardiac surgery with a peak incidence on the second day. It still represents a challenge for postoperative prevention and treatment and may have medical and cost implications. METHODS: Ninety-six consecutive patients undergoing CABG for severe coronary artery disease and in sinus rhythm without antiarrhythmic therapy on the second postoperative day were randomized to have or not 24 h of atrial pacing through temporary epicardial wires using a permanent dynamic overdrive algorithm. Holter ECGs recorded the same day in both groups were analyzed to detect AF occurrence. RESULTS: No difference was observed in baseline data between the two study groups, particularly for age, male gender, history of AF, ventricular function, severity of coronary artery disease, preoperative beta-adrenergic blocking agent therapy or P-wave duration. The incidence of AF was significantly lower (p = 0.036) in the paced group (10%) compared with control subjects (27%). Multivariate analysis showed AF incidence to increase with age (p = 0.051) but not in patients with pacing (p = 0.078). It decreased with a better left ventricular ejection fraction only in conjunction with atrial pacing (p = 0.018). CONCLUSIONS: We conclude that continuous atrial pacing with an algorithm for dynamic overdrive reduces significantly incidence of AF the second day after CABG surgery, particularly in patients with preserved left ventricular function.

Successful Cox-maze III procedure combined with mitral valve replacement in a massively thrombosed left atrium.

A case is reported of chronic atrial fibrillation resulting from long-standing rheumatic mitral stenosis complicated by a massively thrombosed left atrium. In this patient, restoration of sinus rhythm and atrial transport function was performed using a Cox-maze III procedure with mitral valve replacement.

Adaptive mechanisms of arterial and venous coronary bypass grafts to an increase in flow demand.

OBJECTIVE: To compare the mechanisms by which arterial and venous grafts increase their flow during pacing induced tachycardia, early and later after coronary bypass surgery. DESIGN: 43 grafts (13 epigastric artery, 15 mammary artery, 15 saphenous vein) evaluated early (9 (3) days (mean (SD)) after bypass surgery were compared with 41 other grafts (15 epigastric, 11 mammary, 15 saphenous vein) evaluated later after surgery (mean 23 months, range 6 to 168 months) by quantitative angiography and intravascular Doppler velocity analysis during atrial pacing. Controls were 17 normal coronary arteries. RESULTS: Baseline graft flow tended to be lower later after surgery than early (41 (16) v 45 (21) ml/min, NS). Blood flow increased during pacing by 30 (16)% early after surgery, less than later after surgery (+46 (18)%, p < 0.001) and less than in normal coronary arteries (+54 (27)%, p < 0.001 v early grafts; NS v late grafts). There was no difference between venous and arterial grafts. No significant vasodilatation was observed during pacing early after surgery in arterial and venous grafts. Later after surgery, significant vasodilatation was observed only in arterial grafts (mammary and epigastric grafts), from 2.41 (0.37) to 2.53 (0. 41) mm (+5.1% v basal, p < 0.001). Early after surgery and in venous grafts later after surgery, the increase in flow was entirely due to an increase in velocity. In later arterial grafts, the relative contribution of the increase in velocity to the increase in flow during pacing was lower in arterial grafts (70 (22)%) than in venous grafts (102 (11)%, p < 0.001) and similar to normal coronary arteries (68 (28)%). CONCLUSIONS: Early and later after surgery, arterial grafts and venous grafts both increase their flow similarly during pacing. Early arterial grafts and venous grafts increase their flow only through an increase in velocity. Later after surgery, arterial grafts act as more physiological conduits and increase their flow in the same way as normal coronary arteries, through an increase in velocity and calibre mediated by the endothelium.

Patent foramen ovale and implantable cardioverter defibrillator.

A case of patent foramen ovale opening was observed concomitantly to a defibrillation threshold determination in the setting of an internal cardioverter defibrillator implantation. The subsequent transient right-to-left shunt was confirmed by a peroperative transoesophageal echocontrast study. The underlying mechanism of this incident may be related to a transient reversal of the interatrial gradient, due to the pre-existence of pulmonary hypertension and tricuspid regurgitation, associated with ongoing mechanical ventilation and modifications of intracardiac pressures regimen secondary to the succeeding ventricular tachyarrhythmia and defibrillation. Paradoxical embolism can be an aetiology for neurologic injury during internal cardioverter defibrillator implantation.

Intraoperative hemodynamic assessment of gastroepiploic artery and saphenous vein bypass grafts: a comparative study.

OBJECTIVE: Blood flow characteristics of right gastroepiploic artery and saphenous vein conduits were compared during bypass surgery. METHODS: This study is based on a consecutive series of 97 patients undergoing a bypass graft to the right coronary artery, posterior descending artery, or posterolateral branch using either a pediculated right gastroepiploic artery (n = 52) or a saphenous vein (n = 45) bypass graft. Flows and velocity profiles were measured with an 8-MHz pulsed-wave Doppler ultrasound flowmeter. Thorough flow measurements were made (1) after cessation of cardiopulmonary bypass and (2) before chest closure. RESULTS: At the end of cardiopulmonary bypass, flow in the right gastroepiploic artery (59. 0 +/- 6.7 mL/min) did not differ (P =.08) from flow in the saphenous vein (46.1 +/- 2.7 mL/min). Mean trace velocity was 11.9 +/- 0.7 cm/s in the right gastroepiploic artery and 11.6 +/- 0.8 cm/s in the saphenous vein (P =.80), but peak systolic velocity was 29.4 +/- 1.2 cm/s for the right gastroepiploic artery and 23.1 +/- 1.3 cm/s for the saphenous vein (P <.001). Likewise, before chest closure, flow was 57.1 +/- 4.7 mL/min in the right gastroepiploic artery and 46.5 +/- 4.0 mL/min in the saphenous vein (P =.10), mean velocity was 12. 9 +/- 0.7 and 11.6 +/- 0.8 cm/s, respectively (P = .22), and systolic peak velocity was 30.0 +/- 1.2 and 22.3 +/- 1.2 cm/s, respectively (P < .001). CONCLUSIONS: There were no flow differences between right gastroepiploic artery and saphenous vein grafts implanted into the same coronary bed in comparable groups of patients. Waveform shape of the right gastroepiploic artery grafts was characterized by a wider spectral dispersion resulting in a higher maximal frequency.

Intraoperative flow measurements in gastroepiploic grafts using pulsed Doppler.

OBJECTIVE: The patency of a pedicled right gastroepiploic artery (RGEA) graft can be compromised by intraoperative twists, kinks or spasms. Therefore, a systematic flow assessment was made in RGEA grafts and was compared with similar measurements made in other types of bypass conduits. METHODS: Intraoperative pulsed Doppler flowmeter measurements obtained in a series of 556 consecutive patients undergoing at least one coronary bypass grafting onto the right coronary system were studied. Eighty-five RGEA grafts were compared with 1427 bypass grafts implanted in the same group of patients and consisted of the following conduits: 442 left internal mammary (LIMA), 149 right internal mammary (RIMA), 831 greater saphenous vein (GSV) and five inferior epigastric (EPIG) grafts. Sequential grafts were excluded from the analysis. RESULTS: Flow measurements and Doppler waveforms were abnormal and required graft repositioning, and the addition of a distal graft or intragraft papaverine injection (only in GSVs) in 29 cases (2.0% of all grafts). These graft corrections were necessary in 5.9% RGEAs, 3.4% LIMAs, 2.0% RIMAs, and 0.7% GSVs (P < 0.001). The relative risk for graft correction was eight times higher for RGEAs than for GSVs (P = 0.002). Flow increased from 8 +/- 2 to 54 +/- 5 ml/min (P < 0.0001). Flow data were significantly influenced by the type of run-off bed (P < 0.001), the measurements obtained in grafts implanted onto the right coronary artery and the left anterior descending artery being superior. Flows in RGEAs, however, were comparable with values obtained in other grafts implanted onto the same recipient coronary artery. CONCLUSIONS: A significantly higher incidence of graft malpositioning caused inadequate flows in RGEAs. However, normal flow values could be restored simply by assigning a better graft orientation under pulsed Doppler flowmeter control. Overall flow capacity of the RGEA did not differ from values obtained in other arterial and venous grafts implanted onto the same recipient arteries.

Increase in circulating endothelial cells in patients with primary chronic venous insufficiency: protective effect of Ginkor Fort in a randomized double-blind, placebo-controlled clinical trial.

One possible mechanism that accounts for the alterations observed in varicose veins is the activation of endothelial cells by ischemia occurring in the leg veins during blood stasis and the cascade of reactions that follows. Because in vitro data suggest that endothelium alteration is a key event in the development of the pathology, it was important to confirm this hypothesis in patients. We used the number of circulating endothelial cells detached from the vascular wall as a criterion of the endothelium injury. We first compared the number of circulating endothelial cells (CECs) in patients with chronic venous insufficiency (CVI) with those of a control population. A twofold increase in the CEC count (1,001+/-127 CEC/ml of plasma compared with 514+/-82 CECs/ml) was observed in CVI patients, which indeed suggests an alteration of the endothelium in this disease. Second, the protective effect of a venotropic drug, Ginkgo biloba extract, troxerutine, and heptaminol (Ginkor Fort), was tested by a randomized double-blind, placebo-controlled clinical trial. In the active-treatment group, the mean values of the CEC count decreased by 14.5% after a 4-week treatment, whereas in the placebo group, the decrease was less (8.4%). The decrease from week 0 to the end of treatment was significantly higher in the active-treatment group than in the placebo group. These results confirm the important role of the endothelium alterations in the development of varicose veins and suggest a potential beneficial action of a venotropic drug on the venous wall.

Off-pump myocardial revascularization for left main stem disease in a high-risk patient.

Off-pump complete myocardial revascularization for three-vessel disease is often limited by the difficulty to approach the obtuse marginal branches. A method of coronary artery bypass grafting without cardiopulmonary bypass used in a high risk patient with left main stem and three-vessel disease is described.

Pulsed Doppler intraoperative flow assessment and midterm coronary graft patency.

BACKGROUND: This study was designed to assess the value of hemodynamic measurements taken intraoperatively in predicting midterm patency of coronary bypass grafts. METHODS: A pulsed Doppler flowmeter was routinely used during operation to determine the hemodynamic parameters of coronary bypass grafts. During a 7-year period, 85 patients underwent angiographic evaluation. As a result, a thorough hemodynamic assessment of 214 grafts (89 arterial and 125 venous) at initial operation was available for analysis. RESULTS: The overall patency rate was 88.3%. The mean flow measured intraoperatively in 168 intact grafts was 60+/-3 mL/min (range, 9 to 230 mL/min), and the resistance was 1.8+/-0.1 peripheral resistance units (range, 0.3 to 9.0 peripheral resistance units). The mean flow was 36+/-5 mL/min (range, 2 to 107 mL/min), and the resistance was 5.9+/-2.0 peripheral resistance units (range, 0.6 to 46.0 peripheral resistance units) in 25 grafts found occluded at angiographic evaluation. Multivariate analysis identified three independent variables associated with a reduced patency rate: increased resistance as measured in the graft (p = 0.012), increasing interval of control angiography (p = 0.006), and preoperative cardiogenic shock (p = 0.040). CONCLUSIONS: The prognosis for midterm patency of aortocoronary bypass grafts depends on the intraoperative hemodynamic status.

Long-term survival after aortic valve replacement for native active infective endocarditis.

BACKGROUND: The objective of this study was to analyse the impact of acute surgery for native aortic valve endocarditis and its influence on the long-term prognosis after surgery. METHODS: A total of 161 patients underwent aortic valve replacement for native active aortic valve endocarditis (NAAVE) during a 29-year period, from 1967 to 1995 (age range: 10 to 72 years; mean 48 +/- 12). The main indication for surgery was progressive congestive heart failure (76%). Other indications were untreatable sepsis (27%), peripheral or central emboli (12%) and, from 1978, echocardiographic evidence of friable, pedunculated vegetations (3%). Streptococcal and staphylococcal infections predominated. Concomitant procedures were performed in 27% of the patients, including mitral and tricuspid valve surgery and coronary bypass procedures. RESULTS: Operative mortality was 8% in the majority of cases caused by heart failure or multi-organ failure. Multivariate logistic regression analysis identified NYHA class IV to be an independent predictor for postoperative death. Long-term survival for discharged patients was 75% at 10 years and 58% at 15 years, with a mortality rate of 3.6%/patient/year. Cox regression analysis identified the year of operation, trivalvular endocarditis and staphylococcal infection as independent predictors of survival. At 10 and 15 years after aortic valve replacement, 91% and 84% of the patients, respectively, were free of recurrent endocarditis. The presence of an abscess cavity at first operation was found to be predictive of recurrent endocarditis. CONCLUSIONS: Valve replacement for NAAVE offers a good chance for a cure and satisfactory long-term survival. Improvements in pre- and per-operative management of the very ill patient, and the use of allograft valves are likely to further improve long-term results. Finally, the presence of staphylococcal endocarditis requires long-term postoperative antibiotic therapy.

Noninvasive functional assessment of left internal mammary artery grafts by transcutaneous Doppler echocardiography.

A noninvasive method to assess left internal mammary artery (LIMA) patency and function would be useful because this vessel is frequently used for revascularization of the left anterior descending coronary artery. The purpose of this study was to assess the feasibility of measuring changes in LIMA velocities by transcutaneous Doppler during dipyridamole-induced vasodilation. Twenty-five patients with a LIMA graft anastomosed to the left anterior descending coronary artery were studied at least 1 month after surgery by the use of a 5 MHz transducer placed in the left supraclavicular fossa. Doppler velocity parameters were measured at baseline and after intravenous administration of dipyridamole. Dipyridamole increased mean velocity by 127% +/- 54% (p < 0.001), systolodiastolic velocity time integral by 89% +/- 31% (p < 0.001), and diastolic-to-systolic peak velocity ratio from 0.7 +/- 0.3 to 1.2 +/- 0.4 (p < 0.001). The dipyridamole-to-baseline mean velocity ratio was 2.3 +/- 0.5. We conclude that it is possible to measure dipyridamole-induced changes in LIMA flow velocities and thus obtain an index of LIMA blood velocity reserve by transcutaneous Doppler echocardiography.