New Proximal Anastomosis Technique for Calcified Ascending Aorta in Coronary Artery Bypass Grafting.

To deal with calcified ascending aorta during coronary artery bypass grafting, we describe an alternative technique to create a clampless proximal anastomosis using a Foley catheter and polypropylene suture. In 30 patients, the number of distal anastomoses averaged 3.1 ± 0.7, and mean time of proximal anastomosis was 18.9 ± 1.3 minutes. Neither early nor late death occurred. Stroke occurred in 2 high-risk patients. At mean 1.6 ± 0.5 years of follow-up, 1 patient sustained recurrent angina, and graft patency was 93%. These favorable outcomes show that this alternative technique is a safe and effective approach to calcified ascending aorta in coronary artery bypass grafting.

Long-term outcomes of PCI vs. CABG for ostial/midshaft lesions in unprotected left main coronary artery.

BACKGROUND: There are limited data on long-term (> 5 years) outcomes of drug-eluting stent (DES) implantation compared with coronary artery bypass grafting (CABG) for ostial/midshaft left main coronary artery (LMCA) lesions. METHODS: Of the 259 consecutive patients in Beijing Anzhen Hospital with ostial/midshaft LMCA lesions, 149 were treated with percutaneous coronary intervention (PCI) with DES and 110 were with CABG. The endpoints of the study were death, repeat revascularization, myocardial infarction (MI), stroke, the composite of cardiac death, and major adverse cardiac and cerebrovascular events (MACCE, the composite of cardiac death, MI, stroke or repeat revascularization).The duration of follow-up is 7.1 years (interquartile range 5.3 to 8.2 years). RESULTS: There is no significant difference between the PCI and CABG group during the median follow-up of 7.1 years (interquartile range: 5.3-8.2 years) in the occurrence of death (HR: 0.727, 95% CI: 0.335-1.578; P = 0.421), the composite endpoint of cardiac death, MI or stroke (HR: 0.730, 95% CI: 0.375-1.421; P = 0.354), MACCE (HR: 1.066, 95% CI: 0.648-1.753; P = 0.801), MI (HR: 1.112, 95% CI: 0.414-2.987; P = 0.833), stroke (HR: 1.875, 95% CI: 0.528-6.659; P = 0.331), and repeat revascularization (HR: 1.590, 95% CI: 0.800-3.161; P = 0.186). These results remained after multivariable adjusting. CONCLUSION: During a follow-up up to 8.2 years, we found that DES implantation had similar endpoint outcomes compared with CABG.

Intramyocardial dissection with concomitant left ventricular aneurysm as a rare complication of myocardial infarction: a case report.

We describe a rare case of a 60-year-old woman suffering from intramyocardial dissection and left ventricular aneurysm secondary to acute myocardial infarction. A rare form of ventricular septal rupture resulted from intramyocardial dissection deterioration, which was identified during echocardiographic follow-up. Surgical repair under beating-heart cardiopulmonary bypass was successful.

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease.

BACKGROUND: There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events. METHODS: All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups. RESULTS: Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3-8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group. CONCLUSIONS: During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.

A pilot study of systolic dyssynchrony index by real-time three-dimensional echocardiography predicting clinical outcomes to surgical ventricular reconstruction in patients with left ventricular aneurysm.

OBJECTIVES: The aim of the study was to detect whether the systolic dyssynchrony index (SDI) assessed by real-time 3D echocardiography (RT3DE) could predict clinical outcomes of patients with ventricular aneurysm in response to surgical ventricular reconstruction (SVR). METHODS: In total, 120 individuals underwent RT3DE, including 30 healthy volunteers and 90 patients with ventricular aneurysm. All patients underwent clinical and echocardiographic assessments at baseline and at 12 months after SVR. The SDI was defined as the SD of time to minimum systolic volume of the 16 left ventricular (LV) segments, expressed in percent RR duration. SVR responder was defined as a >15% decrease in LV end-systolic volume, reduction in NYHA functional class or 20% relative increase in the LV ejection fraction (LVEF). RESULTS: The SDI was significantly higher in patients with aneurysm, at 14.3% compared with 2.0% in healthy volunteers (P <0.047). The SDI was negatively correlated with the LVEF. After SVR, 86 patients were responders. In this patient subgroup, the SDI exhibited an immediate significant decrease (to 7.7%; P <0.034) and a progressive decrease during 12 months of follow-up (to 4.9%; P <0.044). The SDI can discriminate SVR responders. Receiver-operating characteristic curve analysis yielded cut-off values of SDI 14.3% best associated with SVR response; area under the curve was 0.79 with reduction in NYHA class, 0.86 with increase in EF and 0.66 with decrease in the end-systolic volume. CONCLUSIONS: RT3DE can be used to assess LV mechanical dyssynchrony in patients with aneurysm. SVR produces a mechanical intraventricular resynchronization and SDI can predict improvement following SVR.

Outcomes of middle cardiac vein arterialization via internal mammary/thoracic artery anastomosis.

OBJECTIVE: Cardiac vein arterialization is seldom applied for treating right coronary artery disease. This study aimed to improve outcomes of cardiac vein arterialization in a porcine model using intramammary artery anastomosis. METHODS: A chronic, stenotic coronary artery model was established in 12 of 14 Chinese experimental miniature pigs of either sex, which were randomly divided into equal control (n =6) and experimental (n = 6) groups. In experimental animals, blood flow was reconstructed in the right coronary artery using intramammary artery. Arterialization involved dissection of right internal mammary artery from bifurcation to apex of thorax followed by end-to-side anastomosis of internal mammary artery and middle cardiac vein plus posterior descending branch of right coronary artery. Intraoperative heart rate was maintained at 110 beats/min. Graft flow assessment and echocardiography were performed when blood pressure and heart rate normalized. RESULTS: The experimental group had significantly higher mean endocardial and epicardial blood flow postoperatively than control group (mean endocardial blood flow: 0.37 vs. 0.14 ml/(g*min), p<0.001; mean epicardial blood flow: 0.29 vs. 0.22, p = 0.014). Transmural blood flow was also higher in experimental group than in control group (0.33 vs. 0.19, p<0.001); ejection fraction increased from 0.46% at baseline to 0.51% (p = 0.0038) at 6 hours postoperatively, and mean blood flow of internal mammary artery was 44.50, perfusion index 0.73 at postoperative 6 months, 43.33 and 0.80 at 3 months. CONCLUSION: Successful cardiac vein arterialization via intramammary artery in a porcine model suggests that this may be a viable method for reconstructing blood flow in chronic, severe coronary artery disease.

The application of intraoperative transit time flow measurement to accurately assess anastomotic quality in sequential vein grafting.

OBJECTIVES: Intraoperative transit time flow measurement (TTFM) is widely used to assess anastomotic quality in coronary artery bypass grafting (CABG). However, in sequential vein grafting, the flow characteristics collected by the conventional TTFM method are usually associated with total graft flow and might not accurately indicate the quality of every distal anastomosis in a sequential graft. The purpose of our study was to examine a new TTFM method that could assess the quality of each distal anastomosis in a sequential graft more reliably than the conventional TTFM approach. METHODS: Two TTFM methods were tested in 84 patients who underwent sequential saphenous off-pump CABG in Beijing An Zhen Hospital between April and August 2012. In the conventional TTFM method, normal blood flow in the sequential graft was maintained during the measurement, and the flow probe was placed a few centimetres above the anastomosis to be evaluated. In the new method, blood flow in the sequential graft was temporarily reduced during the measurement by placing an atraumatic bulldog clamp at the graft a few centimetres distal to the anastomosis to be evaluated, while the position of the flow probe remained the same as in the conventional method. This new TTFM method was named the flow reduction TTFM. Graft flow parameters measured by both methods were compared. RESULTS: Compared with the conventional TTFM, the flow reduction TTFM resulted in significantly lower mean graft blood flow (P < 0.05); in contrast, yielded significantly higher pulsatility index (P < 0.05). Diastolic filling was not significantly different between the two methods and was >50% in both cases. Interestingly, the flow reduction TTFM identified two defective middle distal anastomoses that the conventional TTFM failed to detect. Graft flows near the defective distal anastomoses were improved substantially after revision. CONCLUSIONS: In this study, we found that temporary reduction of graft flow during TTFM seemed to enhance the sensitivity of TTFM to less-than-critical anastomotic defects in a sequential graft and to improve the overall accuracy of the intraoperative assessment of anastomotic quality in sequential vein grafting.

Epicardial unipolar radiofrequency ablation for left ventricular aneurysm related ventricular arrhythmia.

We report a case of a 62-year-old Chinese man with typical triple-vessel lesions and apical left ventricular aneurysm accompanied with ventricular tachycardia. Off-pump coronary artery bypass (OPCAB) grafting was performed in combination with epicardial unipolar radiofrequency ablation and linear closure of left ventricular aneurysm. The patient recovered well without postoperative complications. Holter monitoring showed no recurrence of the ventricular arrhythmia and the attack frequency of arrhythmia decreased significantly. The patient has been angina-free for 25 months since the operation and shows increasing exercise tolerance. Thus, left ventricular aneurysm plication combined with epicardial unipolar radiofrequency ablation during OPCAB may be beneficial for patients with ventricular aneurysm and preoperative malignant ventricular arrhythmia.

Off-pump anteroapical aneurysm plication following left ventricular postinfarction aneurysm: effect on cardiac function, clinical status and survival.

BACKGROUND: In patients with coronary disease and aneurysm, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. We report our results with off-pump aneurysm plication after ventricular aneurysm with relative wall thinning. METHODS: We retrospectively reviewed the records of 248 patients who had an operation for postinfarction left ventricular aneurysm. Reconstruction was accomplished by off-pump anteroapical aneurysm plication. The following variables were recorded: preoperative clinical, angiographic and echocardiographic findings and operative procedures. Outcomes were early mortality, long-term survival and poor 5-year result, defined as the need for transplantation or repeated hospitalization for congestive heart failure. Risk factors were pinpointed using the t test and survival curves. Independent risk factors were identified using Cox regression methods. RESULTS: Hospital mortality was low (2.0%). Mean follow-up was 5.8 (standard deviation [SD] 3.8) years. Actuarial survival at 1 and 5 years was 94% and 84%. Among the 232 survivors, 200 were in functional class I or II, and the average increase in ejection fraction was 14.0% (SD 3.1%). As determined by multivariable analysis, factors predicting poor outcome were advanced age, ejection fraction less than 0.35, conicity index less than 1, end-systolic volume index greater than 80 mL/m2, advanced New York Heart Association functional class and congestive heart failure. CONCLUSION: Using wall thinning as a criterion for patient selection, the technique of off-pump anteroapical aneurysm plication can be performed with low operative mortality and provides good symptomatic relief and long-term survival.

Total Arterial Off-pump Coronary Revascularization with a Bilateral Internal Mammary Artery Y Graft (208 cases).

OBJECTIVE: The aim was to evaluate the early outcome of off-pump coronary artery bypass grafting (OPCABG) with a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. MATERIALS AND METHODS: From October 2002 to December 2008, 208 patients (196 male and 12 female patients) underwent OPCABG by only using a BIMA Y configuration graft. The average age of the patients was 56.5±11.3 years, with the age range being 33-78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semiskeletonization skill was used to harvest the two IMAs, and then the free right internal mammary artery was anastomosed end-to-side to the in situ left internal mammary artery to composite a Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery for the patients. Graft patency was assessed by using the HT311 transit time flowmeter (USA Transonic Systems Inc.), intraoperatively. RESULTS: We performed distal anastomoses of the grafts in 728 patients, the average being 3.5±1.3 per person. No one died and got recurrent angina within 30 days after operation. CONCLUSION: OPCABG by using the BIMA Y graft was safe and effective to achieve total arterial revascularization, and avoid surgical operation on the ascending aorta, and other incisions.

Epicardial radiofrequency ablation for left ventricular aneurysm related ventricular arrhythmias during off-pump coronary artery bypass surgery.

BACKGROUND: Left ventricular aneurysm (LVA) is one of the serious complications after acute myocardial infarction. We attempted to evaluate the preliminary efficacy of LVA repair combined with epicardial radiofrequency ablation for ventricular arrhythmia during off-pump coronary artery bypass grafting (OPCAB). METHODS: From June 2009 to April 2011, 31 patients with LVA had angina symptoms and ventricular arrhythmia. In all patients, circular and cross-shaped radiofrequency epicardial ablations were performed using unipolar ablation pen along the border between the aneurysm wall and normal cardiac tissue and in the central zone of the aneurysms, followed by a linear placation of ventricular aneurysms on beating heart. RESULTS: All the patients showed complete recovery. The average number of grafted vessels was 2.7 ± 1.3. Intraoperative examinations revealed that the ventricular arrhythmia was effectively controlled by radiofrequency ablation. All cases had been followed up for one year. Holter monitoring revealed a significant reduction in ventricular arrhythmias (P < 0.05). Echocardiography showed significant increase in left ventricular ejection fraction (P < 0.05) and decrease in left ventricular end-diastolic diameter (P < 0.05). CONCLUSIONS: For patients with ventricular aneurysm and preoperative malignant arrhythmia, aneurysm repair plus epicardial radiofrequency ablation in OPCAB was found to be an effective and feasible therapeutic technique. However, medium- to long-term therapeutic efficacy of this method remains to be determined by future studies and observations.

High volume practice proved the safety of off-pump coronary artery bypass surgery in left main coronary artery lesions: a two-year single center experience.

BACKGROUND: Left main coronary artery (LMCA) stenosis has been recognized as a risk factor for early death among patients undergoing coronary artery bypass grafting (CABG). This study aimed to assess if LMCA lesions pose an additional risk of early or mid-term mortality and/or a major adverse cardiac and cerebrovascular event (MACCE) after off-pump coronary artery bypass grafting (OPCABG), compared with non-left main coronary artery stenosis (non-mainstem disease). METHODS: From January 1, 2009 to December 31, 2010, 4869 patients had a primary isolated OPCABG procedure at Beijing Anzhen Hospital. According to the pathology of LMCA lesions, they were retrospectively classified as a non-mainstem disease group (n = 3933) or a LMCA group (n = 936). Propensity scores were used to match the two groups, patients from the non-mainstem disease group (n = 831) were also randomly selected to match patients from the LMCA group (n = 831). Freedom from MACCE in the two groups was calculated using the Kaplan-Meier method. RESULTS: The difference in the mortality and the rate of MACCE during the first 30 days between the non-mainstem disease group and the LMCA group did not reach statistical significance (P = 0.429, P = 0.127 respectively). With a mean follow-up of (12.8 ± 7.5) months and a cumulative follow-up of 1769.6 patient-years, the difference in the freedom from MACCEs between the two groups, calculated through Kaplan-Meier method, did not reach statistical significance (P = 0.831). CONCLUSION: Analysis of a high volume of OPCABG procedures proved that LMCA lesions do not pose additional early and mid-term risk to OPCABG. Therefore, a LMCA lesion is as safe as non-mainstem disease lesion during the OPCABG procedure.

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft.

OBJECTIVE: To evaluate the outcome of off-pump coronary artery bypass grafting (OPCABG) using a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. METHODS: From October 2002 to December 2008, 208 patients (196 males and 12 females) underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33-78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries (IMAs), and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery (LIMA) in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intra-operatively with the HT311 transit time flowmeter. RESULTS: A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5 ± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation. CONCLUSIONS: OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.

Off-pump anteroapical aneurysm plication for left ventricular post-infarction aneurysm: long-term results.

BACKGROUND: The temporal response to off-pump anteroapical aneurysm plication has not been well defined. We have evaluated the long-term clinical and functional results of this technique and compared the efficacy with the patch modeling repair. METHODS: From March 2005 to May 2010, 163 (115 men and 48 women) consecutive patients were operated on for post-infarction left ventricular aneurysm (LVA), 54 patients underwent patch remodeling (group A) and 109 patients underwent off-pump anteroapical aneurysm plication repair (group B). All patients had simultaneous coronary revascularization, other operative procedures included septoplasty in eight and ablation of ventricular tachycardia in six. Follow-up ranged from 1 to 5 years, short-term and mid-term outcomes, including complications, cardiac function, and mortality, were assessed. RESULTS: Early mortality was 1.8% for all patients (group A 1 death vs. group B 2 deaths, not significant (NS)). Peri-operative support included intraaortic balloon pumping in 16 (9.8%), (group A 6 patients vs. group B 10 patients, NS) and inotropic drugs in 84 (51.5%), (group A 34 vs. group B 50, NS). During a mean follow-up of (3.7±0.8) years, eight patients died, with four due to cardiac-related causes. No patient required transplantation, and two required use of an implantable cardioverter-defibrillator for ventricular tachycardia. Survival at 1 and 5 years was 95% and 86%, respectively. It did not differ significantly between group A and group B. Functional class improved from 2.90 ± 0.59 to 1.65 ± 0.54 among the mid-term survivors (P < 0.001), with no significant difference between the two groups. Pre-operative risk factors for mortality or poor function were ejection fraction (EF) < 0.35 (OR = 7.9, 95%CI 1.6 - 40.0); congestive heart failure (CHF) (OR = 4.4, 95%CI 1.0 - 19.0); end-systolic volume index (ESVI) > 80 ml/m(2) (OR = 3.7, 95%CI 1.0 - 14.0); and advanced age > 70 years (OR = 2.4, 95%CI 1.0 - 12.0). CONCLUSIONS: The technique of off-pump anteroapical aneurysm plication associated with coronary grafting can be performed with low operative mortality, providing good symptomatic relief and long-term survival, and similar results can be achieved with patch modeling repair.

Coronary stenting versus bypass surgery in heart failure patients with preserved ejection fraction.

BACKGROUND: The optimal revascularization strategy in patients with heart failure with preserved ejection fraction (HFPEF) remains unclear. The aim of the present study was to compare the effects of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with HFPEF. METHODS: From July 2003 through September 2005, a total of 920 patients with coronary artery disease (CAD) and HFPEF (ejection fraction ≥ 50%) underwent PCI (n = 350) or CABG (n = 570). We compared the groups with respect to the primary outcome of mortality, and the secondary outcomes of main adverse cardiac and cerebral vascular events (MACCE), including death, myocardial infarction, stroke and repeat revascularization, at a median follow-up of 543 days. RESULTS: In-hospital mortality was significantly lower in the PCI group than in the CABG group (0.3% vs. 2.5%, adjusted P = 0.016). During follow-up, there was no significant difference in the two groups with regard to mortality rates (2.3% vs. 3.5%, adjusted P = 0.423). Patients receiving PCI had higher MACCE rates as compared with patients receiving CABG (13.4% vs. 4.0%, adjusted P < 0.001), mainly due to higher rate of repeat revascularization (adjusted P < 0.001). Independent predictors of mortality were age, New York Heart Association (NYHA) class and chronic total occlusion. CONCLUSION: Among patients with CAD and HFPEF, PCI was shown to be as good as CABG with respect to the mortality rate, although there was a higher rate of repeat revascularization in patients undergoing PCI.

Anteroapical aneurysm plication improves mechanical intraventricular dyssynchrony in patients with anterior myocardial infarction.

BACKGROUND: Left ventricular (LV) dyssynchrony has been described to occur in patients with myocardial infarction. Dyssynchrony of left ventricular mechanical contraction produces adverse hemodynamic consequences. This study aimed to test the capacity of geometric rebuilding by aneurysm plication to restore a more synchronous contractile pattern after a mechanical, rather than electrical, intervention. METHODS: A total of sixty patients with anterior myocardial infarction, QRS duration < 120 ms, electively undergoing operation between January 2008 and January 2010 were included for analysis. Real-time 3-dimensional echocardiography was performed to assess LV function, LV systolic and diastolic dyssynchrony by measuring ejection fraction (EF), peak ejection rate (PER), peak filling rate (PFR) and LV dyssynchrony. LV dyssynchrony was defined as the systolic dyssynchrony of the time to reach the minimum systolic volume for 16 LV segments, expressed in percent cardiac cycle, systolic dyssynchrony index (SDI). We compared changes of LV dyssynchrony at different interval times. RESULTS: LV contraction was significantly asynchronous because preoperative SDI was higher, EF, PER and PFR were lowered. Compared with function after operation, LV mechanical intraventricular resynchronization was improved with decreased SDI ((8.7 ± 0.5)% vs. (14.3 ± 1.6)%, P = 0.01); LV function was improved with EF increasing ((43 ± 9)% vs. (37 ± 7)%, P = 0.001), and LV systolic and diastolic dyssynchrony was improved with more rapid PFR (199.4 ± 15.6 vs. 148.4 ± 21.2, P = 0.002) and PER (212.4 ± 14.5 vs. 156.3 ± 26.2, P = 0.001). CONCLUSIONS: Systolic and diastolic dyssynchrony was highly prevalent in patients with aneurysm, irrespective of QRS duration. Aneurysm plication produces a mechanical intraventricular resynchronization.

Ostial left main coronary artery stenosis as an additional risk factor in off-pump coronary artery bypass grafting.

BACKGROUND: Our aim was to determine whether general left main coronary artery stenosis (LMS) and ostial LMS pose additional risks after off-pump coronary artery bypass grafting (CABG) relative to non-left main coronary artery stenosis. METHODS: From January 1, 2008, to December 31, 2009, 4366 patients underwent primary isolated off-pump CABG at Beijing Anzhen Hospital. Disease was retrospectively classified as non-left main disease (n = 3523), nonostial LMS (n = 765), and ostial LMS (n = 78). Groups were propensity score matched. Kaplan-Meier freedoms from major adverse cardiac and cerebrovascular events (MACCEs) were calculated. RESULTS: During the first 30 postoperative days, mortality was significantly higher in the ostial LMS group (6.41%) than in non-left main disease (0.855%, χ(2) = 7.78, P = .005) and nonostial LMS (1.28%, χ(2) = 4.71, P = .03) groups. Incidence of MACCEs was significantly higher in the ostial LMS group (20.5%) than in non-left main disease (5.98%, P = .000) and nonostial LMS (9.62%, P = .002) groups. Odds ratio for early MACCEs of ostial LMS versus non-left main disease was 3.74 (95% confidence interval, 1.72-8.17). At mean follow-up 12.8 ± 7.5 months and cumulative follow-up 498.5 patient-years, difference among groups in freedom from MACCEs did not reach statistical significance (χ(2) = 2.39, P = .303). CONCLUSIONS: Ostial LMS poses additional early risks of mortality and MACCEs in off-pump CABG. Off-pump CABG for ostial LMS should proceed with greater of intraoperative surveillance and lower threshold for converting to on-pump CABG.

Off-pump sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system.

BACKGROUND: Off-pump coronary artery bypass surgery (OPCAB) has been widely applied in recent years as a less invasive method of myocardial revascularization. This study evaluated the sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system during OPCAB. METHODS: From April 2004 to August 2010, patients with diffuse right coronary lesions were studied retrospectively and divided into two groups. Group 1 included seventeen patients who underwent this surgery while group 2 included twenty-one patients without right coronary artery surgical therapy. All patients presented with symptoms of angina. Blood flow of bridged vessels was measured. The perioperative ventricular parameters including left ventricular ejection fraction and end diastolic diameter were compared. During follow-up, myocardial nuclide imaging and coronary angiography were carried out. RESULTS: Off-pump coronary artery bypass was performed with an average of 3.6 grafts per patient. Hospital mortality was zero. At the time of follow-up, the patients in group 1 recovered better than in group 2 (P < 0.05). In both groups, the mean New York Heart Association (NYHA) class and ejection fraction increased significantly (P < 0.001) and the mean left ventricular end-diastolic diameter decreased significantly (P < 0.05). Myocardial blood supply of inferior wall in group 1 was obviously improved by myocardial nuclide imaging. Coronary angiography for eight patients in group 1 verified that there was blood flow to myocardium in the arterialized vein. CONCLUSIONS: Sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system can be performed during OPCAB. A postoperative improvement in the cardiac functions and the quality of life was documented, increasing our expectation for extensive application.