Association Between Coronary Artery Bypass Surgical Techniques and Postoperative Stroke.

Background The impact of the coronary artery bypass grafting (CABG) technique (on- versus off-pump, single versus multiple aortic clamping) on postoperative neurological outcome remains a matter of controversy. The aim of this study was to assess the association between the incidence of postoperative stroke and the degree of aortic manipulation in one of the largest contemporary CABG series. Methods and Results A retrospective, multicenter, international study was conducted in 25 388 patients undergoing isolated CABG procedures with on-pump CABG (ONCAB) or off-pump CABG (OPCAB) technique including single or multiple aortic clamping. Postoperative stroke was defined as a postoperative neurological deficit lasting more than 24 hours and associated with evidence of a brain lesion on computed tomography. The degree of aortic manipulation was assumed to be higher for on-pump versus off-pump surgery and for multiple versus single or no aortic clamping. Logistic regression and propensity matching were used. ONCAB procedures were performed in 17 231 cases and OPCAB in 8157. The incidence of postoperative stroke was significantly lower in the OPCAB group even after propensity matching (0.4% OPCAB versus 1.2% ONCAB, P=0.02). In the ONCAB group (but not in the OPCAB arm) the use of single aortic clamping was associated with significantly reduced postoperative stroke rate (odds ratio, 0.05; 95% CI, 0.008 to 0.07 [P<0.001]). Conclusions OPCAB and the use of single aortic clamping in the ONCAB arm were associated with a reduced incidence of postoperative stroke. Our data confirm a strong association between aortic manipulation and neurological outcome after CABG surgery.

Everything in the "right" place: multifocal transient ST segment elevation in patient with single coronary artery arising from the right Valsalva sinus.

Single coronary artery (SCA) is a rare coronary anomaly that occurs with an incidence of 0.024%. We report the case of an 83-year-old woman with a Lipton's type 3 SCA, which is the rarest anomaly within this group, occurring only in the 0.004% of general population.  The clinical presentation of this patient was chest pain at rest with multifocal transient ST segment elevation as a marker of multifocal ischemia secondary to severe three vessels coronary artery disease (CAD). This patient was proposed for coronary artery bypass grafting (CABG) with an excellent mid-term outcome.

A Case of Type I Debranching Complicated by Anastomotic Pseudoaneurysm: Do Not Ask Too Much of the Ascending Aorta.

Treatment of aortic arch aneurysm with standard open surgery is technically demanding, and associated morbidity and mortality are not insignificant. In high-risk patients, hybrid procedures with debranching and reimplantation or bypass of the aortic arch vessel followed by thoracic endovascular aortic repair (TEVAR) in the aortic arch represent a valid alternative to open surgery. However, when the ascending aorta is mildly dilated, the risk of retrograde dissection increases sharply. Here, we report a case of thoracic aortic aneurysm, with normal ascending aorta diameter, treated with Type I debranching and anterograde TEVAR complicated by anastomotic pseudoaneurysm and acute endocarditis, treated ultimately with ascending aortic repair and aortic valve replacement.

Impact of preoperative thrombocytopenia on the outcome after coronary artery bypass grafting.

The impact of thrombocytopenia on postoperative bleeding and other major adverse events after cardiac surgery is unclear. This issue was investigated in a series of patients who underwent isolated coronary artery bypass grafting (CABG) from the prospective, multicenter E-CABG registry. Preoperative thrombocytopenia was defined as preoperative platelet count <150 × 109/L and it was considered moderate-severe when preoperative platelet count was <100 × 109/L. Multilevel mixed-effects regression analysis was performed to adjust the effect of thrombocytopenia on outcomes for baseline and operative covariates as well as for interinstitutional differences in patient-blood management. Among 7189 patients included in this analysis, 599 (8.3%) had preoperative thrombocytopenia. Patient with preoperative thrombocytopenia had an increased chest drainage output at 12 h (mean, 519 vs. 456 mL, adjusted coeff. 39, 95%CI 18-60) and rates of severe-massive bleeding (Universal Definition of Perioperative Bleeding (UDPB) severity grades 3-4: 12.7% vs. 8.1%, adjusted OR 1.47, 95%CI 1.11-1.93; E-CABG bleeding severity grades 2-3: 10.4% vs. 6.1%, adjusted OR 1.78, 95%CI 1.30-2.43). Thrombocytopenia was associated with an increased risk of hospital/30-day death (3.2% vs. 1.9%, adjusted OR 2.02, 95%CI 1.20-3.42), 1-year death (5.7% vs. 3.4%, adjusted HR 1.68, 95%CI 1.16-2.44), deep sternal wound infection (3.5% vs. 2.4%, adjusted OR 1.65, 95%CI 1.02-2.66), acute kidney injury (28.1% vs. 22.2%, OR 1.45, 1.18-1.78), and prolonged stay in the intensive care unit (mean, 3.6 vs 2.8 days, adjusted coeff. 0.74, 95%CI 0.40-1.09). Similar results were observed in a subset of patients with moderate-severe thrombocytopenia (51 patients, 0.7%). In particular, these patients had a markedly higher rate of acute kidney injury (40%, adjusted OR, 1.94, 95%CI 1.05-3.57), resternotomy for bleeding (7.8%, adjusted OR 3.49, 95%CI 1.20-10.21), and severe-massive bleeding (UDPB severity grades 3-4: 23.5%, adjusted OR 3.08, 95%CI 1.52-6.22; E-CABG bleeding severity grades 2-3: 23.5%, adjusted OR 4.43, 95%CI 2.15-9.15) compared to patients with normal preoperative platelet count. Mild preoperative thrombocytopenia is associated with increased risk of severe-massive bleeding, mortality, and other major adverse events after CABG. Such risks are markedly increased in patients with moderate-severe preoperative thrombocytopenia.

Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience.

OBJECTIVES: Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS: We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS: Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS: Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.

The use of RemoweLL oxygenator-integrated device in the prevention of the complications related to aortic valve surgery in the elderly patient: Preliminary results.

Background The effects of fat microembolization due to cardiopulmonary bypass are well known in cardiac surgery. Our aim is to evaluate the use of the RemoweLL device (Eurosets, Medolla, Italy) during elective aortic valve replacement in elderly patients (>70 years old) to rate its biochemical and clinical effects. The RemoweLL device is an oxygenator-integrated reservoir which combines two strategies for fat emboli and leucocytes removal: filtration and supernatant elimination. Methods Forty-four elderly patients were enrolled and assigned randomly to a Group A (standard device) and a Group B (RemoweLL). Biochemical effects were evaluated by blood samples, which were tested for white blood cells, neutrophils, protein SP-100 and interleukin 6 besides standard lab tests. Our clinical endpoints were any type of neurological, cardiac, respiratory, gastrointestinal or renal complications, and length of stay in the intensive care unit. Statistical analysis was carried out with chi square test for non-parametric data; t test and analysis of variance for repeated measures were used for parametric data. Results Group B showed lower levels of white blood cells, neutrophils, interleukin 6 and protein SP-100 immediately and 24 hours after the operation. Group B also showed a lower amount of neurocognitive type II dysfunction even if the length of stay in the ICU did not change. Conclusions The RemoweLL system is safe and effective in reducing inflammatory response to cardiopulmonary bypass and it could be a useful tool in minimizing negative effects of cardiopulmonary bypass; however, it does not seem to have any effect on elderly patients' hospital stay.

The role of genetic testing in the prevention of acute aortic dissection.

Although much has been learned about disease of the thoracic aorta, most diagnosis of thoracic aortic aneurysm (TAA) is still incidental. The importance of the genetic aspects in thoracic aortic disease is overwhelming, and today different mutations which cause TAA or alter its natural history have been discovered. Technological advance has made available testing which detects genetic mutations linked to TAA. This article analyses the genetic aspects of TAA and describes the possible role of genetic tests in the clinical setting in preventing devastating complications of TAA.

Aortic centres should represent the standard of care for acute aortic syndrome.

Background Existing evidence suggests that patients affected by acute aortic syndromes (AAS) may benefit from treatment at dedicated specialized aortic centres. The purpose of the present study was to perform a meta-analysis to evaluate the impact aortic service configuration has in clinical outcomes in AAS patients. Methods The design was a quantitative and qualitative review of observational studies. We searched PubMed/ MEDLINE, EMBASE, and Cochrane Library from inception to the end of December 2017 to identify eligible articles. Areas of interest included hospital and surgeon volume activity, presence of a multidisciplinary thoracic aortic surgery program, and a dedicated on-call aortic team. Participants were patients undergoing repair for AAS, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were adopted for synthesizing hospital/30-day mortality. Results A total of 79,131 adult patients from a total of 30 studies were obtained. No randomized studies were identified. Pooled unadjusted ORs showed that patients treated in high-volume centres or by high-volume surgeons were associated with lower mortality rates (OR 0.51; 95% CI 0.46-0.56, and OR 0.41, 95% CI 0.25-0.66, respectively). Pooled adjusted estimates for both high-volume centres and surgeons confirmed these survival benefits (adjusted OR, 0.56; 95% CI 0.45-0.70, respectively). Patients treated in centres that introduced a specific multidisciplinary aortic program and a dedicated on-call aortic team also showed a significant reduction in mortality (OR 0.31; 95% CI 0.19-0.5, and OR 0.37; 95% CI 0.15-0.87, respectively). Conclusions We found that specialist aortic care improves outcomes and decreases mortality in patients affected by AAS.

Gender differences in outcomes after aortic aneurysm surgery should foster further research to improve screening and prevention programmes.

Background Gender-related biases in outcomes after thoracic aortic surgery are an important factor to consider in the prevention of potential complications related to aortic diseases and in the analysis of surgical results. Methods The aim of this study is to provide an up-to-date review of gender-related differences in the epidemiology, specific risk factors, outcome, and screening and prevention programmes in aortic aneurysms. Results Female patients affected by aortic disease still have worse outcomes and higher early and late mortality than men. It is difficult to plan new specific strategies to improve outcomes in women undergoing major aortic surgery, given that the true explanations for their poorer outcomes are as yet not clearly identified. Some authors recommend further investigation of hormonal or molecular explanations for the sex differences in aortic disease. Others stress the need for quality improvement projects to quantify the preoperative risk in high-risk populations using non-invasive tests such as cardiopulmonary exercise testing. Conclusions The treatment of patients classified as high risk could thus be optimised before surgery becomes necessary by means of numerous strategies, such as the administration of high-dose statin therapy, antiplatelet treatment, optimal control of hypertension, lifestyle improvement with smoking cessation, weight loss and careful control of diabetes. Future efforts are needed to understand better the gender differences in the diagnosis, management and outcome of aortic aneurysm disease, and for appropriate and modern management of female patients.

Thoracic Endovascular Aortic Repair Through Cardiac Apex in the Setting of Thoracic Aortic Rupture.

Treatment of thoracic aortic rupture poses a substantial challenge for the aortic surgeon. The advent of thoracic endovascular aortic repair (TEVAR) revolutionized the treatment of this heterogeneous group of diseases. Some patients suitable for TEVAR, however, present severe peripheral vascular diseases that can prevent standard retrograde delivery of the stent graft through the femoral artery. In this report, we present a case series of 5 patients with thoracic aortic rupture successfully treated with cardiac transapical TEVAR.

A rare case of gint lipomatous hypertrophy of the atrial septum.

Benign lipomatous lesion of the heart includes  an heterogeneous group of entities including neoplastic, congenital and reparative phenomena. Among these lipomas and lipomatous hypertrophy of the atrial septum ( LHIS) represent the most common lesion. Patients suffering from LHIS are often asymptomatic, however atrial fibrillation, congestive heart failure and supraventricular tachycardia are typical findings. Here we present a rare case of LHIS symptomatic  for asthenia and dyspnea.

Prognostic Impact of Prolonged Cross-Clamp Time in Coronary Artery Bypass Grafting.

BACKGROUND: The prognostic impact of cross-clamp time (XCT) in patients undergoing isolated coronary artery bypass grafting (CABG) has not been thoroughly investigated. MATERIAL AND METHODS: 2957 patients who underwent on-pump isolated CABG from the prospective multicentre E-CABG study were the subjects of this analysis. RESULTS: The mean XCT in this series was 58±25minutes Cross-clamp time was >60 minutes in 1134 patients (38.3%), >75minutes in 619 patients (20.9%) and >90minutes in 296 patients (10.0%). Multivariate analysis showed that XCT was an independent predictor of 30-day mortality (p<0.0001, OR 1.027, 95%CI 1.015-1.039) along with age (p<0.0001), female gender (p=0.001), pulmonary disease (p=0.001), poor mobility (p=0.002), urgency status (p=0.007), critical preoperative status (p=0.002) and participating centres (p=0.015). Adjusted risk of 30-day mortality was highest for XCT >75minutes (2.9% vs. 1.7%, p=0.002, OR 3.479, 95%CI 1.609-7.520). Analysis of 428 propensity score matched pairs showed that XCT >75minutes was associated with significantly increased risk of early mortality, prolonged use of inotropes, postoperative use of intra-aortic balloon pump, use of extracorporeal membrane oxygenation, atrial fibrillation, prolonged stay in the intensive care unit and of composite major adverse events. CONCLUSIONS: Isolated CABG is currently performed with prolonged XCT in a significant number of patients and this seems to be a determinant of poor early outcome.

Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly.

Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.

Unusual Locations for Cardiac Papillary Fibroelastomas.

Papillary fibroelastomas (PFEs) are rare and benign cardiac tumors which usually are localized on the valves (mostly on the aortic valve), though they may originate also from the ventricles or atrial walls. Whilst, in the large majority of cases, these lesions are asymptomatic they may cause serious complications such as thromboembolic events, or more rarely valvular dysfunctions. Surgical excision is necessary for a symptomatic lesion. The management of asymptomatic lesions is not defined. Herein are reported the details of a miniseries of six cases operated on at the authors' institution between 2005 and 2015. A review of the current literature suggests that PFE is a rare but potentially treatable cause of thromboembolic events, and must be borne in mind during the differential diagnosis of cardioembolic stroke. The surgical excision of PFEs is safe and definitive.

The impact of minor blood transfusion on the outcome after coronary artery bypass grafting.

PURPOSE: To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). METHODS: Sixteen cardiac surgical centers contributed to the prospective European CABG registry (E-CABG). 1014 patients receiving 1-2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs. RESULTS: In 827 propensity score matched pairs, transfusion of 1-2 RBC units did not affect the risk of in-hospital/30-day death (p=0.523) or stroke (p=0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p=0.008), sternal wound infection (p=0.001), postoperative use of antibiotics (p=0.001), prolonged use of inotropes (p<0.0001), use of intra-aortic balloon pump (p=0.012), length of intensive care unit stay (p<0.0001) and length of in-hospital stay (p<0.0001). Matched paired analysis excluding pre- and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in-hospital/30-day death. CONCLUSION: Minor perioperative bleeding and subsequent transfusion of 1-2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low-volume RBC transfusion may improve the outcome after CABG.

Venoarterial extracorporeal membrane oxygenation after coronary artery bypass grafting: Results of a multicenter study.

BACKGROUND: The evidence of the benefits of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is scarce. METHODS: We analyzed the outcomes of patients who received VA-ECMO therapy due to cardiac or respiratory failure after isolated CABG in 12 centers between 2005 and 2016. Patients treated preoperatively with ECMO were excluded from this study. RESULTS: VA-ECMO was employed in 148 patients after CABG for median of 5.0days (mean, 6.4, SD 5.6days). In-hospital mortality was 64.2%. Pooled in-hospital mortality was 65.9% without significant heterogeneity between the centers (I2 8.6%). The proportion of VA-ECMO in each center did not affect in-hospital mortality (p=0.861). No patients underwent heart transplantation and six patients received a left ventricular assist device. Logistic regression showed that creatinine clearance (p=0.004, OR 0.98, 95% CI 0.97-0.99), pulmonary disease (p=0.018, OR 4.42, 95% CI 1.29-15.15) and pre-VA-ECMO blood lactate (p=0.015, OR 1.10, 95% CI 1.02-1.18) were independent baseline predictors of in-hospital mortality. One-, 2-, and 3-year survival was 31.0%, 27.9%, and 26.1%, respectively. CONCLUSIONS: One third of patients with need for VA-ECMO after CABG survive to discharge. In view of the burden of resources associated with VA-ECMO treatment and the limited number of patients surviving to discharge, further studies are needed to identify patients who may benefit the most from this treatment.

A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach.

PURPOSE: The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation. METHODS: A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3 years' experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure. RESULTS: The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p = 0.040) in the short-axis group (69 ± 74 s) than in the long-axis group (98 ± 103 s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p < 0.001), first-puncture success rate (86 vs. 67%, p = 0.003), and first-puncture single-pass success rate (72 vs. 48%, p = 0.002), and with fewer needle redirections (0.39 ± 0.88 vs. 0.88 ± 1.15, p = 0.001), skin punctures (1.12 ± 0.38 vs. 1.28 ± 0.54, p = 0.019), and complications (3 vs. 13%, p = 0.028). CONCLUSIONS: The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.

Renal resistive index by transesophageal and transparietal echo-doppler imaging for the prediction of acute kidney injury in patients undergoing major heart surgery.

BACKGROUND: Acute kidney injury (AKI) following major heart surgery (MHS) is associated with early decrease in renal blood flow and worsened prognosis. Doppler-derived renal resistive index (RRI), which reflects renal vascular resistance, may predict the development of AKI in patients undergoing MHS. METHODS: We studied 60 consecutive patients (mean age 69.5 years, range 30-88, 41 males) undergoing MHS. We measured RRI, both at the renal sinus and intraparenchymally, by transesophageal echo-Doppler ultrasound (TE-EDus) at anesthesia induction and at the end of surgery in all patients. Additionally, we measured RRI by external transparietal echo-Doppler ultrasound (TP-EDus) at the following time points: anesthesia induction, end of surgery, 4 and 24 h from cardiopulmonary bypass (CPB) start. We also measured serum neutrophil gelatinase associated lipocalin (NGAL) at the same time points. RESULTS: AKI [serum creatinine (sCr) increase ≥0.3 mg/dl vs. baseline within 72 h] developed in 23/60 (38.3 %) patients, with two requiring dialysis. Systemic hemodynamic parameters were similar in the patients who developed AKI (AKI+) and in those who did not (AKI-). Intraparenchymal RRI at end-surgery was significantly higher in AKI+ compared to AKI- patients, both at TE-EDus and TP-EDus (TE-EDus mean difference, p = 0.004; TP-EDus mean difference, p = 0.013; difference between TE-EDus and TP-EDus results, p = 0.066), although the predictive performance was limited with both methods (area under the curve [AUC] of the receiver-operator characteristics: 0.71 and 0.70 for TE-EDus and TP-EDus, respectively). Serum NGAL values were higher in AKI + than in AKI- patients (anesthesia induction, p = 0.037; end-surgery, p = 0.007; 4 h from CPB start, p = 0.093; 24 h from CPB start, p = 0.024. However, combining RRI with serum NGAL at end-surgery did not provide a clear-cut advantage in predicting AKI. CONCLUSIONS: In patients undergoing MHS, increased echo-Doppler ultrasound-derived RRI at end-surgery is significantly associated with the risk of AKI, but has limited practical utility for identifying the patients who will develop AKI.