Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution.

BACKGROUND: Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan. METHODS: In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively. RESULTS: The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization. CONCLUSION: Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

[Early and mid-term results of the transapical aortic valve Symetis Acurate TA: a viable solution in high-risk patients with severe vascular disease]. / Risultati a breve e medio termine della valvola aortica transapicale Symetis Acurate TA: valida soluzione nei pazienti vasculopatici ad alto rischio.

BACKGROUND: Aortic valve stenosis is the most common valvular disease in the elderly. Transcatheter aortic valve implantation represents a viable alternative to conventional aortic valve replacement. In our Department, the transapical approach is the preferred method in patients with severe peripheral vascular disease. The aim of this study was to analyze the early and midterm results of Symetis Acurate TA implantation in our series. METHODS: From June 2013 to January 2017, 21 patients with severe peripheral vascular disease (11 male, mean age 78 ± 2.8 years) underwent transapical implantation of the Symetis Acurate TA device. Mean logistic EuroSCORE I was 21.9 ± 8.6, mean left ventricular ejection fraction was 51.9 ± 12.2%, and mean aortic gradient was 46.7 ± 12.3 mmHg. Valve implantation was performed through a left anterior minithoracotomy. Patients were followed up on a regular basis. Cardiac echocardiographic assessment was performed at 6 months post-implantation. RESULTS: Valve implantation was successful in all patients. Valve sizes were as follows: 7 size S, 6 size M, and 8 size L. Two patients died before hospital discharge (9.5%). Among survivors, 2 patients showed more than mild aortic regurgitation at discharge. Mean aortic gradient was 13.1 ± 4.3 mmHg (p<0.01). Median follow-up was 11.3 months. Mean NYHA class at follow-up was 1.9 ± 0.4 (p<0.05). Mean actuarial survival was 80%. CONCLUSIONS: Our series, even if small, demonstrates that transapical implantation of the Symetis Acurate TA device represents a viable solution in patients with severe peripheral vascular disease carrying a high operative risk. The relatively high operative mortality may be attributable to the learning curve of our team.

Conventional surgery results in patients originally referred for transcatheter aortic valve implantation.

AIMS: Transcatheter aortic valve implantation (TAVI) is increasingly considered as a viable alternative to conventional aortic valve replacement (AVR) in high-risk patients. Long-term results, however, are still scarce and medical community hesitates in enlarging indications to lower-risk patients. Moreover, available devices are expensive and a strict potential candidate selection is necessary. METHODS: From April 2008 to August 2012, a total of 212 patients, originally referred for percutaneous treatment, were thoroughly evaluated by the aortic team of our department in order to choose the optimal procedure. Of them, 55 patients (35 women; 20 men) were considered as still acceptable candidates for conventional AVR. RESULTS: Mean age was 80.7 ±â€Š4.7 years; mean additive and logistic Euroscore I were 9.7 ±â€Š1.8 and 17.8 ±â€Š9.5%, respectively. Mean Euroscore II was 7.9 ±â€Š5.5%. Mean New York Heart Association class was 2.9 ±â€Š0.5. The majority of patients (87.2%) presented a geriatric frailty score of 0-1. Four patients showed a heavily calcified ascending aorta, and five patients (9%) underwent reoperations. Hospital mortality was 10.9% (six patients). Mean follow-up was 535.9 ±â€Š407.4 days (range: 6-1365 days). Six other patients died during this period for a mean survival of 74.4 ±â€Š6.9% at 2 years. Mean New York Heart Association class at 1 year was 1.25 ±â€Š0.5 (P < 0.01 vs. preoperative value). CONCLUSION: AVR should be indicated with caution in high-risk patients originally referred for TAVI. Despite medium-term results being good, with excellent functional status, hospital mortality is not negligible.

Sternal wrapping: developments and results.

BACKGROUND: Postoperative sternal wound complications are infrequent events that negatively affect recovery and may have serious consequences. Sternal wrapping, a technique of sternal care, has hemostatic properties without bone wax, and offers mechanical and microbiologic protection. METHODS: From February 1998 to December 2011, 258 patients in 2 Italian institutions underwent various cardiac surgery procedures with sternal wrapping in place, and were followed up for no less then 6 months. RESULTS: Two (0.8%) extremely compromised patients with ischemic sternal osteonecrosis and deep sternal wound infection required a sternal stabilizing procedure. Four (2%) other patients developed sternal wound complications that were treated entirely medically; 3 of them were very trivial, and 1 was an atypical mediastinitis without sternal involvement. Overall, 46.1% of patients (45.3% of isolated coronary artery bypass, 49.3% of isolated on-pump coronary artery bypass, and 18.2% of off-pump coronary artery bypass patients) were transfused. None of the complications was related to sternal wrapping, bleeding from the sternal edge, or sternal wound problems. CONCLUSIONS: Sternal wrapping showed a very low incidence and severity of sternal wound complications, with good prevention of sternal osteomyelitis. Hemostatic properties were satisfactory, with transfusion rates within an acceptable range.

Pulmonary pseudoaneurysm: uncommon complication after total aortic arch operation.

Pulmonary pseudoaneurysms are an uncommon but life-threatening condition of congenital or acquired cause, most commonly involving the branch pulmonary arteries and generally requiring emergent intervention. We describe a case of postoperative main pulmonary artery pseudoaneurysm after a complex aortic arch procedure, in which thoracic computed tomography provided full information for its definition before surgical correction.

Absorption of carbon dioxide during endoscopic vein harvest.

OBJECTIVES: Carbon dioxide (CO(2)) insufflation was used by some devices for endoscopic vein harvest to create a subcutaneous tunnel and facilitate the vein harvest. In the literature, some cases of CO(2) micro- and macro-embolisms or hypercarbia during this procedure are described. The purpose of this study was to evaluate if the use of an open CO(2) system rather than a sealed system might be associated with different CO(2) absorption during the procedure. METHODS: Patients were randomized into two groups: those patients in the first group were submitted to endoscopic vein harvest using a sealed CO(2) insufflation; in the second group, the harvest was undertaken with an open CO(2) insufflation. Partial pressure of CO(2) in the arterial blood (PaCO(2)) and end-tidal CO(2) (ETCO(2)) was recorded following anaesthesia induction and before the endoscopic procedure (T0), every 10 min during the endoscopic step (T1) and end after 10 min from the CO(2) insufflation termination (T2). RESULTS: A total of 60 patients were enrolled. PaCO(2) increased significantly between T0, T1 and T2 in both groups (P = 0.0001) during the endoscopic harvest, but the PaCO(2) level was significantly higher in the group that used the sealed system (44.5 ± 7.9 vs 39.7 ± 7.9 mmHg) at the end of the procedure (P = 0.01). No significant differences between end-tidal CO(2) measured at the same intervals between groups were detected. CONCLUSIONS: There was a constant increase in the blood gas concentration compared with the basal pre-procedure values. Sealed systems were associated with a significantly higher CO(2) concentration at the end of the procedure compared with the open ones.

Cardiopulmonary bypass line sternal wrapping: technical tips.

Cardiopulmonary bypass line sternal wrapping (SW) is a new approach to sternal care which avoids bone wax and offers mechanical protection and a shield from bacterial contamination, with beneficial effects on sternal healing. Since its introduction in February 2008, the technique has undergone some developments: it is possible to harvest internal thoracic arteries with SW in place and its haemostatic properties have improved.

Cardiopulmonary bypass line sternal wrapping for protection and haemostasis.

Sternal marrow haemostasis is often obtained with the application of bone wax, with potential side effects pertaining to sternal wound healing. We illustrate an alternative technique which also offers some protection to sternal edges. Two lengths of tubing from the discarded cardiopulmonary bypass (CPB) circuit are cut longitudinally on one side. After sternotomy they are placed across each sternal edge and kept in position by two stitches and the spreader blades. They are removed just before sternal closure.