Endoscopic vein harvesting: a guide for approaching difficult cases and assessing patients preoperatively.

Coronary artery bypass grafting remains the most commonly performed cardiac surgical procedure worldwide. The long saphenous vein still presides as the first choice conduit as a second graft in multivessel coronary artery bypass grafting surgery. Traditionally, the long saphenous vein has been harvested with an open approach which can potentially result in significant wound complications in certain circumstances. Endoscopic vein harvesting is a minimally invasive vein harvesting technique, which requires a single 2-3 cm incision and is associated with a quicker return to normal daily activities, decreased wound complications and better quality of life in the longer term. There is a learning curve associated with endoscopic vein harvesting adoption and there are certain patient factors that can prove to be challenging when adopting an endoscopic approach. This commentary aims to provide a concise guide of certain challenging patient factors that operators may encounter during endoscopic vein harvesting, and how to approach these patients in both the preoperative and intraoperative settings. We suggest that with appropriate planning and awareness of the challenging patient factors and problematic venous anatomy that exists, the operator can consistently formulate a strategy for ensuring a successful endoscopic harvest.

Epicardial coronary artery Doppler: validation in the animal model.

The aim of the study was to validate a newly-designed epicardial coronary artery Doppler probe and test its detection of changes in coronary blood flow velocity. Left anterior descending (LAD) coronary blood flow and flow velocity were evaluated in four pigs with a pericoronary transit time flow (TTF) probe and a newly-designed epicardial Doppler micro-probe. Four consecutive measurements were taken for each of the following conditions: basal, partial stenosis, occlusion, and reperfusion of the LAD. Mean TTF value (ml/min) was 23.2+/-6.6 in basal condition, 16.2+/-5.7 after partial LAD stenosis, 0.1+/-0.3 during LAD occlusion, and 67.4+/-23.3 at reperfusion (P<0.001). Similar patterns were recorded in terms of Doppler velocity (cm/s) with values of 4.0+/-1.9 in basal condition, 3.5+/-2.3 after partial LAD stenosis, 0.5+/-1.4 during LAD occlusion, and 11.1+/-5.5 at reperfusion (P<0.001). No significant differences in both TTF and Doppler velocity were detected between basal condition and partial LAD stenosis (P=ns). Epicardial coronary arterial Doppler represents a valuable tool to detect coronary arterial flow velocity in basal condition. Although changes in flow velocity are easily recorded after coronary occlusion and reperfusion, modifications after partial coronary stenosis are not clearly defined.

Heparin-bonded circuits versus nonheparin-bonded circuits: an evaluation of their effect on clinical outcomes.

Heparinization of the blood contact surface in cardiopulmonary bypass circuits has been promoted as an important step in the development of open heart surgery. As it decreases the inflammatory response resulting from the extracorporeal circulation, it may have a positive effect on clinical outcomes. This meta-analysis was carried out to examine if heparin-bonded circuits (HBCs) reduce the need for blood products and improve overall clinical outcome. A systematic literature search was performed to identify randomized controlled trials reporting outcomes of HBCs compared with non-HBCs. Primary outcomes assessed were postoperative blood/blood-product transfusion and blood loss. Secondary outcomes included all-cause mortality, acute postoperative myocardial infarction, stroke, re-sternotomy for postoperative bleeding, wound infection, atrial fibrillation, duration of ventilation, intensive care unit (ICU) and hospital-length of stay (LOS). Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Quality of the included studies and heterogeneity were assessed. From an initial review of 762-published studies, 41-randomized trials fulfilled the inclusion criteria, leaving 3434-patients' data for analysis. HBCs significantly decreased the incidence of blood transfusion required (OR=0.8; 95% CI=0.6:0.9, P=0.004). It also significantly decreased re-sternotomy (OR=0.6; 95% CI=0.4:0.8, P=0.002), duration of ventilation (WMD= -1.3h; 95% CI= -1.9:-0.6, P<0.001), ICU-LOS (WMD= -9.3h; 95% CI=-14.7:-3.9, P<0.001) and hospital-LOS (WMD= -0.5 day; 95% CI= -0.9:-0.1, P=0.02). HBCs had no effect on other adverse events evaluated. Although HBCs showed a positive effect on some of the clinical outcomes, we identified only marginal differences for other outcomes. Further evaluation of the cost-effectiveness of this technology is required.

Does off-pump coronary revascularization reduce the release of the cerebral markers, S-100beta and NSE?

OBJECTIVES: The aims of this study were to (1) compare the release of S-100 beta and NSE in off-pump coronary artery bypass grafting (CABG) versus on-pump surgery; (2) investigate whether the S-100 beta and NSE serum concentrations correlate with cardiopulmonary bypass (CPB) duration. MATERIALS AND METHODS: Between October 2002 and May 2004, 42 patients undergoing first time CABG surgery were enrolled in the study. The exclusion criteria were: LVEF<35%, age>70 years, previous myocardial infarction, REDO surgery, the presence of valvular heart disease and/or cerebrovascular disease, abnormal preoperative carotid vessels angiography, coronary artery disease involving the distal circumflex artery, renal dysfunction, coagulopathy. The patients were randomly assigned either to undergo on-pump CABG surgery [group I, n=24 patients] or off-pump CABG [group II, n=18 patients]. Blood was not re-transfused from the cardiotomy suction. All patients presenting haemolysis were excluded from the study. RESULTS: The preoperative S-100beta was 0.13+/-0.08 (microg/l) and NSE 7+/-1.5 (microg/l) in group I and 0.12+/-0.1 (microg/l) and 6.9+/-2.7 (microg/l), respectively in group II. Six hours after the surgery, S-100beta in patients of group I reached a maximum level of 1.38+/-0.4 (microg/l) and NSE of 17.7+/-6.5 (microg/l) compared to 0.5+/-0.11 (microg/l) [S-100B] and NSE 8.6+/-4.2 (microg/l) in group II (p=0.001). Three (12%) patients in group I and none (0%) in group II suffered postoperative delirium, p=0.247. No strokes occurred linear regression analysis revealed a strong correlation between cardiopulmonary bypass duration and S-100beta and NSE peak levels, p<0.0021 (r(2)=0.36) and p<0.0001 (r=0.81), respectively. CONCLUSION: Coronary artery bypass surgery with CPB causes a significantly greater increase in NSE and S-100beta serum levels than off-pump surgery and correlates with CPB duration.

Repair of complete atrioventricular septal defects in patients weighing less than 5 kg.

BACKGROUND: The aim of this study was to evaluate the impact of weight less than 5 kg at operation on mortality and morbidity in patients with atrioventricular septal defect (AVSDc) undergoing total correction. METHODS: Between January 1990 and December 2002, 190 consecutive patients with AVSDc underwent total biventricular correction. They were divided into two groups: group I (n = 64 patients weighing < 5 kg) and group II (n = 126 patients weighing > 5 kg). Associated major cardiac malformations were found in 49 (25.8%) patients. Associated left atrioventricular valve (LAVV) malformations were found in 35 (18.4%) patients. The mean follow-up time was 4.1 +/- 2.9 years (range 2 months-10.7 years). RESULTS: The in-hospital mortality in group I was 7.8% (5 patients) versus 8.7% (11 patients) in group II (p = 0.95). Major associated cardiac malformations (p < 0.001) and pulmonary hypertension (p = 0.006) were found to be strong predictors for poor postoperative survival. At discharge the mean LAVVR grade in group I was 1.45 +/- 1.2 versus 1.2 +/- 1 in group II (p = 0.13). The actuarial overall survival rates at 1, 3, 5, and 7 years were 96.5%, 92.5%, 91.5%, and 89% respectively and the actuarial overall reoperation free survival rates at 1, 3, 5, and 7 years were 95%, 87%, 84%, and 73%. Twenty-three patients underwent reoperation due to severe left atrioventricular valve regurgitation (LAVVR). Strong predictors for overall reoperation free survival were the operation year before 1995 (p < 0.001), postoperative LAVVR greater than or equal to 2 (p = 0.006), major associated cardiac malformations (p = 0.00034), associated LAVV malformations (p = 0.0044), and non or partial LAVV cleft closure (p = 0.012). The actuarial survival rates between patients weighing less than 5 kg versus patients weighing more than 5 kg were similar (p = 0.51); instead the overall reoperation free survival was significantly lower in patients weighing less than 5 kg (p = 0.022) according to the log-rank test. Weight less than 5 kg (p = 0.023, beta = -0.6) was one of the predictors for reoperation due to severe LAVVR in this series. CONCLUSIONS: We may conclude that in the current era repair of AVSDc can be carried out successfully in patients less than 5 kg, however, weight less than 5 kg at initial complete repair seems to be a predictor for late reoperation due to LAVVR. Suture separation at the cleft site or between the leaflets of the newly created mitral valve and the patch remain the main causes of postoperative LAVVR in patients weighing less than 5 kg.

Anomalous origin of the right pulmonary artery from the ascending aorta.

OBJECTIVES: The aim was to review our experience with the surgical repair of the anomalous origin of the right pulmonary artery (AORPA) from the aorta. MATERIALS AND METHOD: Between January 1991 and March 2001, five patients with AORPA underwent surgical correction. One patient presented isolated AOPA from the aorta. Implantation of the anomalous PA to the main PA trunk was performed by (1). direct anatomosis employing an autologous pericardial patch in two patients; (2). using an aortic flap in two patients with AORPA; and (3). using an aortic and pulmonary flaps in another patient. The mean follow-up time was 27 months. RESULTS: One patient died due to progressive heart failure unresponsive to inotropic support. Early postoperative pulmonary hypertension crisis was identified in patient 4, that was managed by intravenous prostacyclin. The same patient necessitated mechanical ventilation for 11 days. The mean residual gradient for all survivors was 9.5 +/- 4 mmHg. The postoperative Tc-99 m scintigraphy demonstrated 72 +/- 4.5(%) lung perfusion. At follow-up the survival was 100%. None of the followed patients required reoperation. CONCLUSION: The AORPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. The techniques employing autologous tissues for enlarging and lengthening the AORPA seem to be associated with better results in terms of postoperative restenosis.

Repair of complete atrioventricular septal defect with tetralogy of fallot: our experience and literature review.

OBJECTIVES: The aim of this report is to describe the rationale of our surgical approach, to explore the best management for complete atrioventricular septal defect associated with the tetralogy of Fallot (CAVSD-TOF), and to present our outcome in relation to the previously reported series. MATERIALS AND METHODS: Between January 1990 and January 2002, 17 consecutive children with CAVSD-TOF underwent complete correction. Nine patients (53%) underwent previous palliation. Mean age at repair was 2.9 +/- 1.9 years. Mean gradient across the right ventricular outflow tract was 63 +/- 16 mmHg. All children underwent closure of septal defect with a one-patch technique, employing autologous pericardial patch. Maximal tissue was preserved for LAVV reconstruction by making these incisions along the RV aspect of the ventricular septal crest. LAVV annuloplasty was performed in 10 (59%) patients. Six patients (35%) required a transannular patch. RESULTS: Three (17.6%) hospital deaths occurred in this series. Causes of death included progressive heart failure in two patients and multiple organ failure in the other patient. Two patients required mediastinal exploration due to significant bleeding. Dysrhythmias were identified in 4 of 11 patients undergoing a right ventriculotomy versus none of the patients undergoing a transatrial transpulmonary approach (p = ns). The mean intensive care unit stay was 3.2 +/- 2.4 days. Two patients required late reoperation due to severe LAVV regurgitation at 8.5 and 21 months, respectively, after the intracardiac complete repair. The mean follow-up time was 36 +/- 34 months. All patients survived and are in NYHA functional class I or II. The LAVV regurgitation grade at follow-up was significantly lower than soon after operation, 1.1 +/- 0.4 versus 1.7 +/- 0.5 (p = 0.002). At follow-up, the mean gradient across the right ventricular outflow tract was 17 +/- 6 mmHg, significantly lower than preoperatively (p < 0.001). CONCLUSIONS: Complete repair in patients with CAVSD-TOF seems to offer acceptable early and mid-term outcome in terms of mortality, morbidity, and reoperation rate. Palliation prior to complete repair may be reserved in specific cases presenting small pulmonary arteries or severely cyanotic neonates. The RVOT should be managed in the same fashion as for isolated TOF; however, a transatrial transpulmonary approach is our approach of choice.

Beating heart ischemic mitral valve repair and coronary revascularization in patients with impaired left ventricular function.

OBJECTIVE: The aim of this study is to evaluate in a cohort of patients with impaired left ventricular (LV) function and ischemic mitral valve regurgitation (MVR), the effects of on-pump/beating heart versus conventional surgery in terms of postoperative mortality and morbidity and LV function improvement. MATERIALS AND METHODS: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III-IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 +/- 7 years and in Group II, 65 +/- 6 years (p = 0.69). RESULTS: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 +/- 1 and 2.7 +/- 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 +/- 6 (%) versus 16 +/- 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. CONCLUSION: We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients.

Postoperative outcome in patients with anomalous origin of one pulmonary artery branch from the aorta.

OBJECTIVES: The aim was to review our experience with the surgical repair of the anomalous origin of one pulmonary branch from the aorta (AOPA). MATERIALS AND METHOD: Between January 1991 and March 2002, eight patients with AOPA underwent surgical correction. Three patients presented isolated AOPA. Five patients presented right AOPA and three, left AOPA. Implantation of the AOPA to the main pulmonary artery was performed by: (I) direct anastomosis in two patients with left AOPA; (II) interposition of a synthetic graft in one patient with left AOPA; (III) employing an autologous pericardial patch in two patients with right AOPA; (IV) using an aortic flap in three other patients with right AOPA. The mean follow-up time was 37.7 months. RESULTS: One patient died postoperatively due to progressive heart failure unresponsive to inotropic support. Early postoperative pulmonary hypertension crisis was identified in another patient. Within 1 year after surgery, the mean residual gradient across the anastomotic site at follow-up was 14+/-8 mmHg. The patient undergoing interposition of a synthetic graft presented a residual gradient of 29 mmHg and underwent reoperation at almost 2.5 years after the first correction. The residual gradient in patients undergoing correction according to technique I was 17+/-3 mmHg, and in patients undergoing implantation of the AOPA according to techniques III or IV was 9.5+/-4.6 mmHg (P=0.11). Similarly, the Tc-99m scintigraphy demonstrated that a lower lung perfusion (the lung perfused from the respective AOPA compared with the contralateral lung) in patients undergoing AOPA implantation according to technique I was 59+/-6(%) and in patients undergoing techniques III or IV was 72+/-4.5(%) (P=0.038). At follow-up, all patients were alive. CONCLUSION: The AOPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. Patients presenting this anomaly may undergo correction using various surgical techniques with acceptable results. The techniques employing autologous tissues for enlarging and lengthening the AOPA seems to be associated with less restenosis at the anastomotic site, however, larger series of patients are required to confirm such outcome.

Postoperative outcome in patients with accessory mitral valve tissue.

Accessory mitral valve tissue (AcMVT) is a rare congenital malformation causing left ventricular outflow tract obstruction (LVOTO). The analysis of various published reports reveals 90 patients presenting with AcMVT, ranging in age from newborns to 77 years old. Severe LVOTO is present in most cases, though mild LVOTO was found in 15 patients (16.7%), and 3 other patients (3.3%) presented with no LVOTO. In our practice, we found this anomaly in 5 patients; one presenting with severe LVOTO, two with mild LVOTO, and another who developed moderate LVOTO after a myocardial infarction episode. 68 patients (75.5%) underwent cardiac surgery, with a postoperative mortality of 6 (8.9%). Postoperatively, a residual mild gradient across the left ventricular outflow tract was identified in 9 patients (13.2%). Nine other patients (13.2%) required reoperation due to severe LVOTO. Mild-to-moderate postoperative mitral or aortic valve regurgitation was found in 7 (10.3%) and 5 (7.3%) patients, respectively. Based on reported intraoperative findings, we have classified this anomaly as Type I-FIXED TYPE (A - nodular, B - Membranous), Type II-Mobile type (A - Pedunculated, B - leaflet-like). Type IIB is divided into 1) rudimentary chordae and 2) developed chordae. Based in our own experience and after the analysis of various reports, we conclude that patients with AcMVT causing LVOTO may undergo safe mass excision with acceptable postoperative mortality and morbidity. The removal of the AcMVT should in no way compromise mitral valve function, and its excision should be made subject to careful evaluation of the surrounding structures.

Anomalous origin of the left pulmonary artery from the aorta. Our experience and literature review.

Three patients with anomalous origin of the left pulmonary artery (AOLPA) from the aorta underwent surgical correction. Two patients presented with an isolated malformation and one with an associated ventricular septal defect. One of the patients with an isolated malformation presented with an AOLPA from the descending thoracic aorta. Implantation of the AOLPA to the main PA trunk was performed by direct anastomosis in two patients and by interposition of a synthetic graft in the other patient with AOLPA from the descending aorta. All patients survived the operation. Low cardiac output was identified in one patient. The mean residual gradient through the anastomotic site was 21 mmHg at follow-up. We found almost 72 cases with AOLPA reported in the literature with a high mortality rate in patients not undergoing surgery. The most frequently found associated malformation is tetralogy of Fallot and ventricular septal defect. AOLPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. Patients with AOLPA can undergo surgical repair with excellent results.

Off-pump total arterial myocardial revascularization according to the right Y-graft configuration.

OBJECTIVES: The aims of this study were as follows: 1) to evaluate the early outcome of the off-pump total arterial myocardial revascularization according to the right y-graft (lambda-graft) configuration and 2) to compare baseline flow and maximum flow between patients undergoing on-pump and off-pump right y-graft (RYG) construction. METHODS: Between December 1998 and January 2001, 47 patients (Group I) and 20 patients (Group II) with three vessel disease underwent on-pump and off-pump coronary artery bypass graft (CABG) respectively according to the RYG configuration. The mean age was 55.5 +/- 4.7 years and 55 +/- 6.4 years in Groups I and II, respectively. The RYG was constructed employing both internal mammary arteries (IMAs) only, in 21 and 8 patients in Groups I and II, respectively, presenting proximal-middle third stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA). The modified RYG configuration employing both IMAs and radial artery (RA) was performed in 26 and 12 patients in Groups I and II, respectively, presenting middle-distal third stenosis of the LAD and distal stenosis of the RCA or posterior descending artery stenosis. Postoperatively all patients underwent transthoracic echo color-Doppler (TTECD) contrast enhanced (by Levovist) before and after adenosine provocative testat one week and three months after operation. RESULTS: There were no hospital deaths. The mean mechanical ventilation was significantly different in Group I versus Group II patients, 18 +/- 4.4 hours versus 13 +/- 5.7 hours, respectively (p = 0.041). The mean intensive care unit stay was 1.5 +/- 0.6 days in Group I and 1 +/- 0.4 days in Group II (p = 0.033). There were no differences between Groups I and II regarding the IMA diameter, mean velocity, and mean flow. At follow-up time, 6 +/- 2.4 months after the surgical procedure, all patients were alive and free of angina. The coronary flow reserve (CFR) at LIMA main stem was significantly higher at three months when compared to the values at one week after the surgical procedure within the same group, (LIMA)CFR (three months) = 2.37 +/- 0.6 versus (LIMA)CFR (one week) = 2.07 +/- 0.4 (p = 0.005) in Group I and (LIMA)CFR (three months) = 2.4 +/- 0.4 versus (LIMA)CFR (one week) = 2.06 +/- 0.3 (p = 0.004) in Group II. Similarly, the CFR at RIMA main stem were significantly higher at three months when compared to the values at one week after the surgical procedure: (RIMA)CFR (three months) = 2.47 +/- 0.7 versus (RIMA)CFR (one week) = 2.1 +/- 0.5 (p = 0.004) in Group I and (RIMA)CFR (three months) = 2.48 +/- 0.5 versus (RIMA)CFR (one week) = 2.08 +/- 0.4 (p = 0.008) in Group II. CONCLUSION: The flow dynamic data, almost identical between patients undergoing off-pump and on-pump total arterial myocardial revascularization (TAMR) according to the RYG configuration, demonstrate that this technique can be applied with excellent results without the employment of cardiopulmonary bypass in selected coronary artery disease patients.