Predominant Use of Bilateral Internal Mammary Arteries in Off-Pump Coronary Artery Bypass Surgery.

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has been shown to provide long-term clinical benefits over single internal mammary artery (SIMA) grafting. Nevertheless, the perceived technical complexity of the procedure and concerns about potential early postoperative complications, particularly sternal wound infections have led to a utilization rate of BIMA grafting of less than 5% in the United States. We systematically compared early (30-day) post-operative outcomes between the BIMA and SIMA cohorts in patients with similar baseline characteristics. A retrospective single center study was conducted on matched patients, using stabilized inverse probability treatment weighting to mitigate bias between the two study cohorts. From 546 off-pump CABG patients initially identified, we examined 328 BIMA and 213 SIMA grafts from the matched samples. Despite utilizing 60.4% BIMA grafts, we observed similar rates of 30-day overall and cardiac mortality between the BIMA and SIMA groups. Rates of 30-day postoperative complications, including superficial and deep sternal wound infections, stroke, sepsis, acute kidney injury, and cardiac arrest, were similar between the two groups. Rates of 30-day overall and cardiac readmission were also similar. Additionally, median length of hospital stays, intensive care unit stay, and ventilation times were similar between the two groups. In conclusion, our data suggest that a BIMA utilization rate of 60.4% in off-pump CABG procedure is achievable without causing any significant increment in early post-operative complications, including deep sternal wound infection.

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease.

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Autologous cell salvage in off-pump coronary artery bypass surgery reduces post-operative complications: a retrospective weighted-matching analysis.

OBJECTIVES: Blood transfusion plays a crucial role in coronary artery bypass grafting (CABG). The choice between autologous cell saver (CS) and allogenic blood transfusion (ABT) has been a continuous debate in the medical community, especially within cardiac surgery. This study aimed to assess the outcomes of off-pump CABG (OPCAB) surgery in patients receiving blood solely via cell salvage compared to those receiving ABT or a combination of ABT and CS perioperatively. METHODS: A total of 414 patients who underwent isolated OPCAB surgery at our cardiovascular clinic were analyzed. Among them, 250 patients (60.4%) received blood via CS alone, while 164 patients (39.6%) received either ABT or a mix of ABT and CS. Stabilized inverse probability treatment weighted (IPTW) matching technique ensured balance in baseline covariates. RESULTS: We found no significant differences in 30-day mortality rates between the CS and ABT groups. The CS group displayed significantly lower rates of overall complications, encompassing stroke, acute kidney injury, atrial fibrillation, and pulmonary complications. Rates of sepsis, readmission, gastrointestinal complications, heparin-induced thrombosis, and deep venous thrombosis were comparable between the two groups. However, in contrast to the ABT group, the CS group exhibited significantly shorter median lengths of hospital stay (LOHS), ICU stay, and ventilation time, along with higher rates of discharge to home rather than acute care facilities. CONCLUSION: Our data suggest that autologous blood transfusion via CS results in fewer perioperative complications and faster recovery following OPCAB procedures as compared to ABT.

Acute Presentation of Critical Aortic Stenosis, Cardiogenic Shock, and the "Heart Team" Approach to Management.

A 65-year-old male was admitted for cardiogenic shock (ejection fraction: 15%) with severe aortic stenosis and regurgitation. He underwent emergency angiography and mechanical circulatory support. A multidisciplinary heart team discussed treatment options. Ultimately, he underwent successful emergency surgical aortic valve replacement with recovery on extracorporeal membrane oxygenation. (Level of Difficulty: Intermediate.).

Redo surgical aortic valve replacement for prosthetic valve valve-in-valve dysfunction.

Transcatheter aortic valve replacement (TAVR) has become the preferred intervention for patients with severe aortic stenosis and significant comorbidities. This technique can also be used for failed bioprosthetic valves and is known as the valve-in-valve (ViV) procedure. Placing TAVR in a small bioprosthesis (<23 mm) can lead to delayed dysfunction of the prosthetic valve. We present a case of a late explanted ViV 8 years post-initial aortic valve replacement and coronary artery bypass grafting, and 3 years post-ViV procedure in a 76-year-old female. A video of the surgical procedure is provided.

Use of a novel bicarbonate-based Impella 5.5 purge solution in a coagulopathic patient.

The Impella 5.5 with Smart Assist (Abiomed) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. The use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.

Off-pump myocardial revascularization with Impella 5.5-assisted for cardiogenic shock.

We report a case of Impella 5.5-assisted off-pump coronary artery bypass grafting for acute myocardial infarction with cardiogenic shock. The Impella 5.5 was placed in the left ventricle during the emergent procedure, and an off-pump coronary artery bypass grafting was successfully performed with exposure of all three walls of the heart. Our findings demonstrated the feasibility of off-pump coronary revascularization in three-vessel disease in a patient assisted with an Impella 5.5 percutaneous left ventricular assist device without displacement of the device during the entire perioperative period.

Twenty-year outcomes of coronary artery bypass grafting utilizing 3 in situ arterial grafts.

OBJECTIVE: The added value of total arterial revascularization in coronary artery bypass grafting becomes particularly apparent when evaluating long-term results. We previously reported on our 10-year outcomes of total arterial revascularization using bilateral internal thoracic and gastroepiploic arteries as in situ grafts in patients with 3-vessel disease. This study aimed to increase the follow-up period to 20 years. METHODS: We updated clinical outcomes of 201 patients operated on between 1992 and 2002. At that time, the technique was primarily performed in patients with a longer life expectancy. Primary end points were overall survival and freedom from the composite of major adverse cardiac events. Secondary end points were the separate cardiac events. RESULTS: Extended follow-up included all patients. The median follow-up time was 19.2 years (interquartile range, 16.2-20.0). The respective 15- and 20-year Kaplan-Meier estimated survival probabilities were 73.9% (95% confidence interval [CI], 67.2%-79.5%) and 63.5% (95% CI, 55.7%-70.4%) for overall survival and 57.9% (95% CI, 50.7%-64.5%) and 47.9% (95% CI, 40.1%-55.3%) for freedom from major adverse cardiac events. The respective estimated cumulative incidences at 15 and 20 years were 7.0% (95% CI, 3.5%-10.6%) and 7.8% (95% CI, 4.0%-11.6%) for myocardial infarction, 8.6% (95% CI, 4.7%-12.5%) and 9.3% (95% CI, 5.2%-13.3%) for percutaneous reintervention, 7.0% (95% CI, 3.5%-10.5%) and 7.0% (95% CI, 3.5%-10.5%) for reoperation, 8.6% (95% CI, 4.7%-12.6%) and 12.9% (95% CI, 7.6%-18.2%) for cardiac death, and 10.8% (95% CI, 6.5%-15.2%) and 15.2% (95% CI, 9.8%-20.6%) for death from other causes. CONCLUSIONS: The use of in situ bilateral internal thoracic and gastroepiploic arteries provides outstanding 15- and 20-year survival and cardiac event-free survival probabilities. Further studies are needed in older patients with more severe comorbidities. Nevertheless, the results from this and scarce other studies on 15- to 20-year outcomes of total arterial revascularization suggest that cardiac surgeons should embrace the application of total arterial grafting to further reduce the risks of long-term cardiac events, especially during the second decade after surgery.

Stopping antiplatelet medication before coronary artery bypass graft surgery: is there an optimal timing to minimize bleeding?

OBJECTIVES: As the indication for antiplatelet medication expands, patients may be exposed to an increased risk of excessive blood loss when cardiac surgery is required. The optimal timing to stop acetylsalicylic acid (ASA) or ASA combined with clopidogrel (ASA+Clo) before surgery is the subject of controversy. METHODS: A total of 1065 patients were selected from a prospective randomized study on the effect of a fibrin sealant application in coronary artery bypass graft surgery [Fibrin sealant Induced Blood Exposure Reduction study; REGISTRATION NUMBER: NTR1386 (http://www.trialregister.nl)], and divided into three groups according to the use of antiplatelet medication within 10 days prior to surgery: (i) ASA only (n = 662), (ii) ASA+Clo (n = 290) or (iii) no antiplatelet medication (n = 113). To investigate if an optimal stop day could be established, we fitted a series of multiple linear regression models, one for each preoperative day (running from Day -10 up to -1). The specific day corresponding to the best fitting model (highest adjusted R(2), with blood loss in the first 48 h postoperatively as the dependent variable) was considered as the best estimate for the optimal stop day. Bootstrap analysis (1000 times) was performed to calculate the corresponding confidence interval. Furthermore, major adverse cardiovascular and cerebral events (MACCE) were evaluated. RESULTS: We could not estimate an optimal stop day for patients using ASA or ASA+Clo prior to their operation. Last use of ASA on Day -2 or earlier significantly decreased the percentage of patients receiving platelet transfusions compared with continuation until surgery (7 vs 13% for Day -1, P = 0.007). In patients using ASA+Clo, this percentage was reduced from 41 to 10 (P < 0.001). There was no association between stop day and the occurrence of MACCE. CONCLUSIONS: There is no clinically relevant effect on blood loss indicating an optimal stop day for ASA alone or in combination with Clo. Last use on Day -2 resulted in the reduction of percentage of patients receiving platelet transfusions, especially in the ASA+Clo group.

Avoiding sternotomy in repeat coronary artery bypass grafting: Feasibility, safety, and mid-term outcome of the transabdominal off-pump technique using the right gastroepiploic artery.

OBJECTIVES: Repeat sternotomy is associated with a substantial risk of cardiovascular injury. We evaluated the feasibility and clinical outcome of a transabdominal approach without sternotomy and without cardiopulmonary bypass in repeat coronary artery bypass grafting, using the right gastroepiploic artery to graft vessels of the inferior wall of the heart. METHODS: From July 1999 to October 2010, 22 patients presenting with only right coronary artery disease underwent reoperation using the transabdominal approach and a skeletonized gastroepiploic artery graft. In all patients but 1, a patent graft to the anterior wall was present. The mean EuroSCORE was 6.4 ± 2.5. RESULTS: All patients had adequate surgical exposure, and no conversion to sternotomy or the use of cardiopulmonary bypass was required. There was no in-hospital mortality. Hospital morbidity included pneumothorax in 1 patient and atrial fibrillation in 2 patients. The median hospital stay was 5 days. Follow-up was complete, and the median follow-up time was 6 years. There were 2 late deaths. Four patients experienced recurrence of angina, of whom three required percutaneous coronary intervention. The estimated freedom from major cardiovascular and cerebrovascular events rate was 70.2% at 6 years. Fourteen patients underwent an exercise stress test at a median interval of 2 years, with all showing no signs of myocardial ischemia. CONCLUSIONS: Transabdominal off-pump coronary artery bypass grafting using the right gastroepiploic artery is a safe and effective procedure with low in-hospital mortality and morbidity and favorable mid-term outcome. In redo operations, this technique excludes the risk of cardiovascular injury.

Outcomes after transcatheter aortic valve implantation: transfemoral versus transapical approach.

BACKGROUND: Transcatheter aortic valve implantation is commonly implanted through a transfemoral (TFA) or transapical approach (TAA) for patients with severe aortic stenosis. This study aimed to describe the clinical and echocardiographic outcomes of TFA versus TAA. METHODS: Clinical and echocardiographic evaluations were performed at baseline, post-TAVI (transcatheter aortic valve implantation), at 6 and 12 months follow-up in 107 consecutive patients who underwent TAVI with balloon-expandable valves. RESULTS: The TFA was performed in 44% and the remaining patients underwent TAA. Although procedural complications were not significantly different in both approaches, more vascular complications were observed in the TFA group (18% vs 5%, p = 0.053). Patients with TAA required shorter fluoroscopy time (median 5 vs 12 min, p < 0.001), less contrast volume (median 80 vs 173 mL, p < 0.001), and similar length of hospitalization, as compared with TFA. Importantly, the early 30-day mortality (TFA: 11.1% vs TAA: 8.5%, p = 0.74) were not significantly different between the 2 approaches. Midterm survival at 6 months and 1 year was comparable between TFA and TAA (6 months: 88.9% vs 85.7% and 1 year: 80.2% vs 85.7%). All patients achieved immediate and sustained improvements in transvalvular hemodynamics, together with significant left ventricular mass regression (137 ± 39 vs 113 ± 30 g/m(2), p < 001) and left atrial volume reduction (48 ± 17 vs 34 ± 14 mL/m(2), p < 0.001) at 6 months or less. CONCLUSIONS: Early, midterm, clinical, and echocardiographic outcomes were comparable in both approaches. However, TAA has the additional benefit of reducing radiation exposure and contrast use intraoperatively without prolonging the length of hospital stay.

Transcatheter aortic valve implantation: role of multi-detector row computed tomography to evaluate prosthesis positioning and deployment in relation to valve function.

AIMS: Aortic regurgitation after transcatheter aortic valve implantation (TAVI) is one of the most frequent complications. However, the underlying mechanisms of this complication remain unclear. The present evaluation studied the anatomic and morphological features of the aortic valve annulus that may predict aortic regurgitation after TAVI. METHODS AND RESULTS: In 53 patients with severe aortic stenosis undergoing TAVI, multi-detector row computed tomography (MDCT) assessment of the aortic valve apparatus was performed. For aortic valve annulus sizing, two orthogonal diameters were measured (coronal and sagittal). In addition, the extent of valve calcifications was quantified. At 1-month follow-up after procedure, MDCT was repeated to evaluate and correlate the prosthesis deployment to the presence of aortic regurgitation. Successful procedure was achieved in 48 (91%) patients. At baseline, MDCT demonstrated an ellipsoid shape of the aortic valve annulus with significantly larger coronal diameter when compared with sagittal diameter (25.1 +/- 2.4 vs. 22.9 +/- 2.0 mm, P < 0.001). At follow-up, MDCT showed a non-circular deployment of the prosthesis in six (14%) patients. Moderate post-procedural aortic regurgitation was observed in five (11%) patients. These patients showed significantly larger aortic valve annulus (27.3 +/- 1.6 vs. 24.8 +/- 2.4 mm, P = 0.007) and more calcified native valves (4174 +/- 1604 vs. 2444 +/- 1237 HU, P = 0.005) at baseline and less favourable deployment of the prosthesis after TAVI. CONCLUSION: Multi-detector row computed tomography enables an accurate sizing of the aortic valve annulus and constitutes a valuable imaging tool to evaluate prosthesis location and deployment after TAVI. In addition, MDCT helps to understand the underlying mechanisms of post-procedural aortic regurgitation.

Comparison of aortic root dimensions and geometries before and after transcatheter aortic valve implantation by 2- and 3-dimensional transesophageal echocardiography and multislice computed tomography.

BACKGROUND: 3D transesophageal echocardiography (TEE) may provide more accurate aortic annular and left ventricular outflow tract (LVOT) dimensions and geometries compared with 2D TEE. We assessed agreements between 2D and 3D TEE measurements with multislice computed tomography (MSCT) and changes in annular/LVOT areas and geometries after transcatheter aortic valve implantations (TAVI). METHODS AND RESULTS: Two-dimensional circular (pixr(2)), 3D circular, and 3D planimetered annular and LVOT areas by TEE were compared with "gold standard" MSCT planimetered areas before TAVI. Mean MSCT planimetered annular area was 4.65+/-0.82 cm(2) before TAVI. Annular areas were underestimated by 2D TEE circular (3.89+/-0.74 cm(2), P<0.001), 3D TEE circular (4.06+/-0.79 cm(2), P<0.001), and 3D TEE planimetered annular areas (4.22+/-0.77 cm(2), P<0.001). Mean MSCT planimetered LVOT area was 4.61+/-1.20 cm(2) before TAVI. LVOT areas were underestimated by 2D TEE circular (3.41+/-0.89 cm(2), P<0.001), 3D TEE circular (3.89+/-0.94 cm(2), P<0.001), and 3D TEE planimetered LVOT areas (4.31+/-1.15 cm(2), P<0.001). Three-dimensional TEE planimetered annular and LVOT areas had the best agreement with respective MSCT planimetered areas. After TAVI, MSCT planimetered (4.65+/-0.82 versus 4.20+/-0.46 cm(2), P<0.001) and 3D TEE planimetered (4.22+/-0.77 versus 3.62+/-0.43 cm(2), P<0.001) annular areas decreased, whereas MSCT planimetered (4.61+/-1.20 versus 4.84+/-1.17 cm(2), P=0.002) and 3D TEE planimetered (4.31+/-1.15 versus 4.55+/-1.21 cm(2), P<0.001) LVOT areas increased. Aortic annulus and LVOT became less elliptical after TAVI. CONCLUSIONS: Before TAVI, 2D and 3D TEE aortic annular/LVOT circular geometric assumption underestimated the respective MSCT planimetered areas. After TAVI, 3D TEE and MSCT planimetered annular areas decreased as it assumes the internal dimensions of the prosthetic valve. However, planimetered LVOT areas increased due to a more circular geometry.