Should bilateral internal thoracic artery grafting be used in elderly patients undergoing coronary artery bypass grafting?

BACKGROUND: Although bilateral internal thoracic artery grafting is associated with improved survival, the use of this technique in the elderly is controversial because of their increased surgical risk and shorter life expectancy. The purpose of this study was to evaluate the effect of age on outcome of patients undergoing bilateral internal thoracic artery grafting. METHODS AND RESULTS: Between 1996 and 2001, 1714 consecutive patients underwent skeletonized bilateral internal thoracic artery grafting, of whom 748 were ≤65 years of age, 688 were between 65 and 75 years of age, and 278 were ≥75 years of age. Operative mortality of the 3 age groups (1.2%, 4.1%, and 5.8%, respectively) was lower than the logistic EuroSCORE predicted mortality (3.9%, 6.5%, and 9.3%, respectively; P<0.001). There were no significant differences among the groups in occurrence of sternal infection (1.3%, 2.6%, and 1.4%, respectively; P=0.171). Mean follow-up was 11.5 years. Kaplan-Meier 10-year survival for patients ≤65, 65 to 75, and >75 years of age was 85%, 65%, and 40%, respectively (P<0.001). These rates were better than the corresponding predicted Charlson Comorbidity Index survival rates (68%, 37%, and 20%, respectively; P<0.001 for all age groups), approaching survival of the sex- and age-matched general population (90%, 70%, and 41%, respectively). Age ≤65 years (hazard ratio, 0.232; 95% confidence interval, 0.188-0.288) and age 65 to 75 years (hazard ratio, 0.499; 95% confidence interval, 0.414-0.602) were independent predictors of improved survival (Cox model). CONCLUSIONS: Bilateral internal thoracic artery grafting should be considered in patients >65 years of age because of the significant survival benefit obtained with this surgical technique with no additional risk of sternal wound infection related to age.

Long-term clinical and echocardiographic follow-up of the freestyle stentless aortic bioprosthesis: the Tel Aviv Medical Center experience.

BACKGROUND: Stentless aortic bioprostheses were designed to provide improved hemodynamic performance and potentially better survival. OBJECTIVES: To report the outcomes of patients after aortic valve replacement with the Freestyle stentless bioprosthesis at the Tel Aviv Medical Center followed for < or = 15 years. METHODS AND RESULTS: Between 1997 and 2011, 268 patients underwent primary aortic valve replacement with a Freestyle bioprosthesis, 211 (79%) of them in the sub-coronary position. Mean age, Charlson comorbidity index and Euro-score were 71.0 +/- 9.2 years, 4.2 +/- 1.5 and 10.2 +/- 11 respectively, and 156 (58%) were male. Peak and mean trans-aortic gradient decreased significantly (75.0 +/- 29.1 vs. 22.8 +/- 9.6 mmHg, P < 0.0001; and 43.4 +/- 17.2 vs. 12.1 +/- 5.4 mmHg, P < 0.0001 respectively) during 3 months of follow-up. Mean overall follow-up was 4.9 +/- 3.1 years and was complete in all patients. In-hospital mortality was 4.1% (n=11) but differed significantly between the first 100 patients operated before 2006 and the last 168 patients operated after January 2006 (8 vs. 3 patients, 8.0% vs. 1.8%, P = 0.01). Overall, 5 and 10 year survival rates were 85 +/- 2.5% and 57.2 +/- 5.7%, respectively. Five year survival was markedly improved in patients operated after January 2006 compared to those operated in the early years of the experience (92.3 +/- 2.3% vs. 76.0 +/- 4.4%, P = 0.0009). All the 21 octogenarians operated after January 2006 survived surgery, with excellent 5 year survival (85.1 +/- 7.9%). Six patients required reoperation during follow-up: structural valve deterioration in five and endocarditis in one. CONCLUSIONS: Aortic valve replacement with the Freestyle bioprosthesis provides good long-term hemodynamic and clinical outcomes, even in octogenarians. Valve calcification is the major (and rare) mode of valve deterioration leading to reoperation in these patients.

Surgical myocardial revascularization versus percutaneous coronary intervention with drug-eluting stents in octogenarian patients.

OBJECTIVE: Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization. METHODS: We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006. RESULTS: Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis. CONCLUSION: Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.

Open heart reoperations after coronary artery bypass grafting: the role of preoperative imaging with multidetector computed tomography.

BACKGROUND: Injury to patent grafts or cardiac chambers may occur during reoperation after coronary artery bypass grafting. Preoperative spatial localization of bypass grafts with computed tomography may improve the safety of these procedures. OBJECTIVES: To characterize patients who undergo CT before repeat operations after previous coronary artery bypass grafting, and evaluate its benefit in terms of surgical outcome. METHODS: We compared 28 patients who underwent cardiac gated CT angiography before reoperation (CT group) to 45 redo patients who were not evaluated with CT (no-CT group). RESULTS: The two groups were similar in most preoperative and operative characteristics. The CT group, however, included more patients with patent saphenous vein grafts and fewer with emergency operations, acute myocardial infarction and need for intraaortic balloon pump support. During mid-sternotomy, there was no injury to grafts in the CT group, while there were two patent grafts and three right ventricular injuries in the no-CT group. There was no significant difference in perioperative mortality (3.6% vs. 8.9%). The overall complication rate in the CT group was 21.4% compared to 42.2% in the no-CT group (P = 0.07). The only independent predictors of postoperative complications were diabetes mellitus, preoperative stroke and preoperative acute MI. CONCLUSIONS: The patency and proximity of patent grafts to the sternum are well demonstrated by multidetector CT and may provide the surgeon with an important roadmap to avoid potential graft injury. A statistical trend towards reduced complications rate was demonstrated among patients who underwent CT angiography before their repeat cardiac operation. Larger series are required to demonstrate a statistically validated complication-free survival benefit of preoperative CT before repeat cardiac surgery.

Comparison between multivessel stenting with drug eluting to the LAD and bilateral internal thoracic artery grafting.

BACKGROUND: Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting. METHODS: From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities. RESULTS: The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015). CONCLUSIONS: Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

[Surgical ventricular restoration--new horizons in the treatment of ischemic cardiomyopathy].

Heart failure is a major health problem with increasing prevalence due to aging of the population and in addition to an increase in effective treatment and early myocardial reperfusion during acute myocardial infarction. Postinfarction left ventricular remodeling is characterized by chamber dilatation with an abnormal spherical shape leading to systolic and diastolic dysfunction frequently associated with mitral valve insufficiency and eventually heart failure. Intensive medical management reduces symptoms and improves survival. However, patients who are in NYHA functional class III or IV still have a poor prognosis. In this review article we will endeavor to summarize the emerging surgical approach "surgical ventricular restoration" for treating ventricular remodeling and ischemic cardiomyopathy. These concepts of restoration of the elliptical shape of the left ventricle and re-establishing the normal structure of the sub-valvular mitral apparatus are performed recently in our department.

Effect of tumor necrosis factor-alpha on endothelial and inducible nitric oxide synthase messenger ribonucleic acid expression and nitric oxide synthesis in ischemic and nonischemic isolated rat heart.

OBJECTIVES: The present study aimed to investigate the influence of endogenous tumor necrosis factor-alpha (TNF-alpha) that was synthesized during ischemia and exogenous TNF-alpha on endothelial and inducible nitric oxide synthase (eNOS and iNOS) messenger ribonucleic acid (mRNA) expression and nitric oxide (NO) production in the isolated rat heart. BACKGROUND: Tumor necrosis factor-alpha is recognized as being a proinflammatory cytokine with a significant cardiodepressant effect. One of the proposed mechanisms for TNF-alpha-induced cardiac contractile dysfunction is increased NO production via iNOS mRNA upregulation, but the role of NO in TNF-alpha-induced myocardial dysfunction is highly controversial. METHODS: Isolated rat hearts studied by a modified Langendorff model were randomly divided into subgroups to investigate the effect of 1-h global cardioplegic ischemia or the effect of 1-h perfusion with exogenous TNF-alpha on the expression of eNOS mRNA and iNOS mRNA and on NO production. RESULTS: After 1 h of ischemia, there were significant increases in TNF levels in the effluent (from hearts), and eNOS mRNA expression had declined (from 0.91 +/- 0.08 to 0.68 +/- 0.19, p < 0.001); but there were no changes in iNOS mRNA expression, and NO was below detectable levels. Perfusion of isolated hearts with TNF-alpha had a cardiodepressant effect and decreased eNOS mRNA expression to 0.67 +/- 0.04 (p < 0.002). Inducible nitric oxide synthase mRNA was unchanged, and NO was below detectable levels. CONCLUSIONS: We believe this is the first study to directly show that TNF-alpha does not increase NO synthesis and release but does downregulate eNOS mRNA in the ischemic and nonischemic isolated rat heart.

No-touch aorta off-pump coronary surgery: the effect on stroke.

OBJECTIVE: Studies examining the neuroprotective effects of off-pump coronary artery bypass grafting have shown inconsistent results. Most studies, however, have not differentiated between clampless and clamp off-pump techniques. The aim of this study was to evaluate the effect of avoiding aortic manipulation on major neurologic outcomes after off-pump coronary artery bypass grafting. METHODS: A total of 700 consecutive patients undergoing multiple-vessel off-pump coronary artery bypass grafting between 2000 and 2003 were included. The 429 patients undergoing aortic no-touch technique were compared with 271 patients in whom partial aortic clamps were applied. The aorta was screened by manual palpation, and epiaortic ultrasonography was used selectively. RESULTS: The frequency of detected atherosclerotic aortic disease was higher in the no-touch group (17.4% vs 5.1%, P < .0001). No-touch revascularization was achieved with arterial conduits, arranged in T-graft or in situ configurations (50%). The respective graft/patient ratios were 2.5 +/- 0.6 and 2.6 +/- 0.6 in the side-clamp and no-touch groups ( P = .009); however, revascularization of the posterolateral myocardial territory was comparable (87% vs 90%, difference not significant). The incidence of stroke (0.2% vs 2.2%, P = .01) was significantly lower in the no-touch group (1/429). Logistic regression identified partial aortic clamping as the only independent predictor of stroke (odds ratio 28.5, confidence interval 0.22-333, P = .009), increasing this risk 28-fold. Peripheral vascular disease ( P = .068), diabetes ( P = .072), and history of stroke ( P = .074) trended toward stroke. CONCLUSIONS: Avoiding partial aortic clamping during off-pump coronary artery bypass grafting provides superior neurologic outcome. The results are reproducible and irrespective of the severity of aortic disease or the method of aortic screening. This technique is recommended whenever technically feasible.

Revascularization of left anterior descending coronary artery in patients with single and multivessel disease: comparison between off-pump internal thoracic artery and drug-eluting stent.

STUDY OBJECTIVES: The left anterior descending artery (LADA), particularly when the proximal segment of the vessel is involved, is a challenging area for percutaneous coronary interventions (PCIs); therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the LADA. This study compares mid-term results of LADA revascularization with a drug-eluting stent (DES), with off-pump coronary artery bypass grafting (OPCAB) in patients with single-vessel or multivessel coronary artery disease (CAD). DESIGN: Matched-groups, retrospective cohort comparison between the DES and OPCAB. PATIENTS: From June 2002 to December 2003, 354 patients underwent myocardial revascularization of the LADA by OPCAB, and 168 by DES. After matching for age, sex, and extent of CAD, two groups (116 patients each) were used to compare the two revascularization modalities. The groups were similar; however, an ejection fraction of <30%, old myocardial infarction, and use of an intraaortic balloon pump were more prevalent in the OPCAB group. RESULTS: The average number of coronary vessels treated per patient in the two groups was similar (OPCAB, 1.97; DES, 1.6; p = 0.581). The 30-day mortality rate was 0.9% in the OPCAB group and 0% in the DES group (p = 0.329). The mean duration of follow-up was 12 months. There was one late death in each group. Angina returned in 31% of patients in the DES group and in 11.2% of the patients in the OPCAB group (p = 0.001). There were 12 reinterventions in the DES group compared to three reinterventions in the surgical group (p = 0.020). The only independent predictor (Cox proportional hazards regression model) of the return of angina (risk ratio [RR], 3.36; 95% confidence interval [CI], 1.57 to 7.14) and reintervention (RR, 3.9; 95% CI, 1.34 to 11.24) was assignment to the DES group. CONCLUSIONS: The mid-term clinical outcome of OPCAB in patients with CAD, including multivessel disease, was better than that for PCIs with only one DES used in patients with similar extents of CAD.

Heparin added to cardioplegic solution inhibits tumor necrosis factor-alpha production and attenuates myocardial ischemic-reperfusion injury.

OBJECTIVES: Tumor necrosis factor (TNF)-alpha is known to be a proinflammatory cytokine that has a pronounced negative inotropic effect and plays an important role in ischemic-reperfusion injury. METHODS: Twenty isolated rat hearts were randomly divided equally into two groups (heparin and non-heparin) and were perfused with a Krebs-Henseleit solution using a modified Langendorff model. The influence of heparin on the synthesis and release of TNF-alpha by isolated rat hearts after 1 h of global cardioplegic ischemia and on left ventricular (LV) performances during 30 min of postischemic reperfusion was investigated. RESULTS: Significant mean (+/- SEM) amounts of TNF-alpha in myocardial tissue (1,149 +/- 33.7 pg/g) and effluent (951.8 +/- 27.3 pg/mL) from the coronary sinus were detected after global cardioplegic ischemia. The addition of heparin to the cardioplegic solution significantly improved the recovery of LV function in the postischemic heart (p < 0.0001 for all measurements). TNF-alpha protein production in the heparin-treated hearts was below detectable levels despite a postischemic increase of TNF-alpha messenger RNA expression in both heparin-treated hearts and nontreated hearts (0.71 +/- 0.06 and 0.8 +/- 0.12 relative optical density, respectively). CONCLUSION: This study shows, for the first time, that heparin causes the inhibition of TNF-alpha protein synthesis and release from the isolated ischemic rat heart within the posttranscriptional stage, and that it prevents the depression of LV function caused by ischemic-reperfusion injury.

Use of intraoperative epiaortic ultrasonography to delineate aortic atheroma.

OBJECTIVE: A cerebrovascular accident (CVA) is a devastating complication of coronary artery bypass grafting (CABG) and a major cause for morbidity and mortality. Aortic manipulation, cannulation, and clamping during CABG may lead to release of atheromatous material from the ascending aorta, which may cause a CVA. This study assessed the hypothesis that the use of intraoperative epiaortic ultrasonography (EAUS) would supplement imaging information with that derived from manual aortic palpation and influence the surgical decision-making approach accordingly. METHODS: After undergoing a mid-sternotomy for CABG, 105 patients underwent EAUS with an 8-MHz transducer ordinarily used for conventional transthoracic echocardiography. The surgical strategy was decided on at three stages: preoperatively, after manual aortic palpation, and following EAUS. RESULTS: The preoperative strategy had assigned 105 patients to the "touched aorta" group that was planned for either on-pump or off-pump CABG (OPCAB) with proximal anastomosis to the aorta. Pathologic lesions of the atheromatotic ascending aorta were evident in 40 patients (38%), with the lesions detected in 22 patients (21%) by both palpation and EAUS, and in 18 patients (17%) by EAUS alone. The planned surgical strategy was changed in 29 patients (28%): 25 patients (24%) were converted from on-pump CABG to OPCAB, and the EAUS influenced the choice of the aortic cannulation, cross-clamping, and proximal anastomosis site in 4 patients (4%). Among the changes in surgical decision making, changes in 11 patients (10%) were based on lesion detection by both manual palpation and EAUS; in 18 patients (17%), changes resulted from pathologic evidence provided by EAUS alone. CONCLUSIONS: This study showed EAUS to be more sensitive in detecting atherosclerotic lesions than manual intraoperative palpation of the ascending aorta. This investigation contributes new data on the effect of EAUS on intraoperative surgical approach in the era of OPCAB. The use of EAUS has emerged as an important tool in intraoperative decision making, and we recommend its use routinely in CABG procedures.

Thermo-wrap technology preserves normothermia better than routine thermal care in patients undergoing off-pump coronary artery bypass and is associated with lower immune response and lesser myocardial damage.

OBJECTIVE: Perioperative hypothermia might be detrimental to the patient undergoing off-pump coronary artery bypass surgery. We assessed the efficacy of the Allon thermoregulation system (MTRE Advanced Technologies Ltd, Or-Akiva, Israel) compared with that of routine thermal care in maintaining normothermia during and after off-pump coronary artery bypass surgery. METHODS: Patients undergoing off-pump coronary artery bypass surgery were perioperatively and randomly warmed with the 2 techniques (n = 45 per group). Core temperature, hemodynamics, and troponin I, interleukin 6, interleukin 8, and interleukin 10 blood levels were assessed. RESULTS: The mean temperature of the patients in the Allon thermoregulation system group (AT group) was significantly ( P < .005) higher than that of the patients receiving routine thermal care (the RTC group); less than 40% of the latter reached 36 degrees C compared with 100% of the former. The cardiac index was higher and the systemic vascular resistance was lower ( P < .05) by 16% and 25%, respectively, in the individuals in the AT group compared with in the individuals in the RTC group during the 4 postoperative hours. End-of-surgery interleukin 6 levels and 24-hour postoperative troponin I levels were significantly ( P < .01) lower in the patients in the AT group than in the RTC group. The RTC group's troponin levels closely correlated with their interleukin 6 levels at the end of the operation ( R = 0.51, P = .002). CONCLUSIONS: Unlike routine thermal care, the Allon thermoregulation system maintains core normothermia in more than 80% of patients undergoing off-pump coronary artery bypass surgery. Normothermia is associated with better cardiac and vascular conditions, a lower cardiac injury rate, and a lower inflammatory response. The close correlation between the increased interleukin 6 and troponin I levels in the routine thermal care group indicates a potential deleterious effect of lowered temperature on the patient's outcome.

Pharmacological preconditioning with monophosphoryl lipid A improves post ischemic diastolic function and modifies TNF-alpha synthesis.

OBJECTIVE: Pharmacologic preconditioning represents an attractive myocardial protection strategy. Tumor necrosis factor-alpha plays an important role in myocardial ischemia-reperfusion injury. We aimed to determine the effect of Monophosphoryl lipid A-induced delayed preconditioning on diastolic and systolic left ventricular function and tumor necrosis factor-alpha synthesis during ischemia and reperfusion. METHODS: Rats (n=10) were pretreated with Monophosphoryl lipid A (350 microg/kg) or vehicle (n=9). Twenty-four hours later, the hearts were isolated and perfused on a Langendorff apparatus. Hemodynamic measurements, tumor necrosis factor-alpha mRNA expression and protein content were studied after stabilization (baseline), after 35 min of global ischemia and at 40 min of reperfusion. RESULTS: Left ventricular developed pressure and peak rate of left ventricular developed pressure (dP/dt) rise were comparable between the animals in the control and Monophosphoryl lipid A treated groups during baseline but were higher in Monophosphoryl lipid A group at reperfusion (74+/-4 vs 51+/-5 mmHg, 3340+/-172 vs 2240+/-156 mmHg/s, respectively, P<0.01). dP/dt fall was significantly lower in the MLA group (2630+/-225v 1580+/-210 mmHg/s, P<0.01) at 40 min of reperfusion as well as end diastolic pressure. Baseline tumor necrosis factor-alpha mRNA (expressed as arbitrary densitometry units) were higher in the Monophosphoryl lipid A group (1.3+/-0.1 vs 0.5+/-0.03, P<0.05) but remained constant after ischemia and reperfusion (1.3+/-0.1 and 1.4+/-0.03, P=0.2), while further increase was observed in the control group (from 1.0+/-0.1 to 1.4+/-0.1, P<0.05). Tumor necrosis factor-alpha protein content from heart effluent in the control group was increased during reperfusion (79+/-30 and 200+/-22pg/ml, P<0.05) but was undetectable in the Monophosphoryl lipid A group. Marked TNF-alpha immunostaining of left ventricular tissue was observed only in the control group but no TNF-alpha staining was evident in the Monophosphoryl lipid A treated group at 40 min of reperfusion. CONCLUSION: Monophosphoryl lipid A-induced preconditioning renders the heart more tolerant to ischemia-reperfusion in terms of left ventricular diastolic and systolic function, and prevents tumor necrosis factor-alpha production during ischemia, through aborting the translation phase of tumor necrosis factor-alpha synthesis.

Off-pump coronary revascularization of the circumflex system: comparison between sequential and nonsequential arterial grafts.

BACKGROUND: Sequential grafting increases the availability of arterial grafts. This study aims to determine the safety and efficacy of sequential grafting of the circumflex coronary distribution performed off-pump. METHODS: Between 2000 and 2003, 136 patients undergoing off-pump sequential arterial grafting of the circumflex territory were compared to 278 patients who received nonsequential grafts to the same area. RESULTS: The grafts/patient ratio was higher in the sequential than the nonsequential group (3.2 +/- .4 and 2.3 +/- .2, respectively, P < .0001). Radial artery conduits and T-grafts were used more often in the sequential group; conversely, bilateral internal thoracic artery configurations were more frequent in the nonsequential groups (P < .0001). There were 1.2 sequential anastomoses per patient. Early mortality (2.2% versus 2.5%), myocardial infarction (2.2% versus 1.1%) and stroke (.7% versus none) rates were comparable. Use of sequentials or other operative confounders had no independent effect on the occurrence of early adverse events (stepwise logistic regression). At 3.5 years, survival was 95.9% and 84.2% in the sequential and nonsequential groups, respectively (P = .231, log-rank). Despite comparable incidence of major adverse cardiac events (MACE) (6.6% versus 8.6%, P = .470) and similar 3.5-year freedom from MACE (88.7% for both groups, P = .682), Cox regression analysis identified sequential grafting as an independent predictor of MACE (P < .0001, HR 19.9), increasing this risk by 20-fold. CONCLUSIONS: Off-pump sequential grafting of the circumflex system may be safely performed. The use of sequentials, however, had an independent effect on increased midterm MACE. The distribution of events suggests culpability of surgical factors and may reflect a learning curve.

Bilateral internal thoracic artery grafting in diabetic patients: short-term and long-term results of a 515-patient series.

BACKGROUND: Despite potential long-term benefits, bilateral internal thoracic artery grafting in diabetics remains controversial because of the risk of sternal infection. We sought to assess the short- and long-term outcome after left-sided bilateral internal thoracic artery grafting and to determine the configuration of choice in diabetic subsets. METHODS: Between 1996 and 2001, 515 diabetics underwent isolated left-sided skeletonized bilateral internal thoracic artery grafting. The outcome of 468 consecutive oral-treated diabetics and 47 selective insulin-treated patients was analyzed. Patients undergoing T-grafting were compared with those undergoing in situ bilateral internal thoracic artery arrangements. RESULTS: The respective rates for early mortality and sternal infections were 2.4% and 1.9% in oral-treated diabetics and 6.3% and 4.3% in insulin-treated diabetics. Multivariate correlates of sternal infection were chronic lung disease (odds ratio, 10), obesity (odds ratio, 7), reoperation (odds ratio, 22), and a creatinine level of 2 mg/dL or more (odds ratio, 8). Five-year survival was 82%. The T-graft (n = 437) and in situ (n = 162) subgroups had comparable baseline profiles. Freedom from cardiac mortality at 6.5 years was 95.6% and 87.6% (P =.277), and freedom from repeat revascularization was 91.5% and 92.7% (P =.860), respectively. The choice of bilateral internal thoracic artery configuration did not appear as a correlate of mortality, cardiac mortality, or major adverse cardiac events. Complementary right-sided gastroepiploic artery (hazard ratio, 0.36) and sequential (hazard ratio, 0.55) grafting were identified as protective factors against the occurrence of major adverse cardiac events. CONCLUSIONS: Routine skeletonized bilateral internal thoracic artery grafting can be implemented safely in oral-treated diabetics. This strategy is associated with a favorable late cardiac outcome and is thus recommended. Both left-sided bilateral internal thoracic artery configurations provide comparable short- and long-term outcomes.

Perioperative hemodynamic and geometric changes of the left ventricle during cardiomyoplasty in goats with dilated left ventricle.

OBJECTIVE: Clinical data have suggested the occurrence of temporary short-term deterioration of the heart following cardiomyoplasty. The purpose of this study was to monitor the short-term hemodynamic effects of cardiomyoplasty in a goat model of a dilated left ventricle, using conductance catheters (ie, pressure-volume loops) and cardiac output measurements. METHODS: Eight female goats underwent acute cardiomyoplasty 8 to 12 weeks after left ventricular (LV) dilatation was induced by a carotid jugular arteriovenous shunt. The cardiomyoplasty procedure was monitored using a Swan-Ganz catheter for cardiac output measurements and a 12-electrode (dual-field) conductance catheter to LV pressure-volume loops. RESULTS: After wrapping the heart with the latissimus dorsi muscle, there was a significant reduction in both cardiac output and LV end-diastolic volume (LVEDV) at 10 min. Partial recovery was observed 45 min later. CONCLUSION: A decrease in both cardiac output and LVEDV was observed following myocardial wrapping. This may explain some of the perioperative and postoperative morbidity and mortality observed following cardiomyoplasty.

Use of novel nonfluoroscopic three-dimensional electroanatomic mapping system to monitor and analyze heart surgery in animal models.

BACKGROUND: The new method of three-dimensional (3D) electroanatomic mapping was presented as an important tool for cardiac imaging and intervention. We present herein the first use of this technology for the monitoring, analysis, and development of cardiac surgery at the preclinical stage. METHODS: The method is based on utilizing a locatable catheter connected to an endocardial mapping and navigating system, to accurately establish the location and orientation of the tip of the mapping catheter and simultaneously record its local electrogram. The 3D geometry of the beating cardiac chamber is reconstructed in real time. The system was tested on six goats that underwent dynamic cardiomyoplasty. Two maps of each animal were performed: preoperative and postoperative during the stimulation protocol of the skeletal muscle. RESULTS: The electroanatomic mapping system provided detailed maps of the left ventricle during the stimulation protocol, which demonstrated a striking geometric difference between the assisted and the unassisted beats. These geometric changes are best described by referring to left ventricular long-axis movements (22.3 +/- 3.8 degrees vs 3.4 +/- 1.6 degrees, p < 0.001), center-of-mass movements (10.4 +/- 3.0 mm vs 3.9 +/- 1.6 mm, p < 0.005), and the changes in upward movement viewed along the base (7.9 +/- 1.9 mm vs 3.6 +/- 1.7 mm, p < 0.01), middle (13.8 +/- 4.0 mm vs 7.3 +/- 1.8 mm, p < 0.005), and the apex of the heart (28.1 +/- 4.5 vs 5.3 +/- 2.3 mm, p < 0.001) [mean +/- SD]. CONCLUSIONS: The 3D electroanatomic mapping system allows detailed reconstruction of the left ventricular geometry and a clear view of the difference between the assisted and the unassisted beats. This novel monitoring system may serve as an important tool for the analysis and development of new techniques in cardiac surgery.

Graft of choice to right coronary system in left-sided bilateral internal thoracic artery grafting.

BACKGROUND: The complementary graft of choice to the right coronary artery system in patients undergoing left-sided bilateral internal thoracic artery grafting has yet to be determined. Saphenous vein graft (SVG) was compared with right gastroepiploic artery (RGEA) as the supplemental conduit to the right coronary artery when left-sided bilateral internal thoracic artery grafting is implemented. METHODS: From April 1996 to July 1999, 234 patients underwent bilateral internal thoracic artery grafting to the left coronary system with RGEA grafted to the posterior descending artery (RGEA group). They were compared with 127 patients with left-sided bilateral internal thoracic artery in whom SVG was used for grafting the right coronary system (SVG group). RESULTS: Female sex (27% versus 14.5%), diabetic patients (40% versus 27%), emergency cases (21% versus 7.3%), and left main coronary artery disease (34% versus 23%) were more prevalent in the SVG group. Number of grafts per patient was higher in the SVG group (3.8 versus 3.5, p = 0.04). Thirty-day mortality was 3.9% in the SVG and 2.6% in the RGEA group (not significant). Occurrence of postoperative complications (myocardial infarctions, strokes, bleeding, and sternal infections) was similar. Return of angina was similar (1.6% versus 3.8% in the SVG and RGEA groups, respectively). Midterm follow-up (4 to 56 months) showed comparable 1-year and 4-year survival (Kaplan-Meier) for both groups (92.8% and 91.7% in the SVG group, and 94.7% and 88% in the RGEA group, respectively). CONCLUSIONS: In patients undergoing left-sided bilateral internal thoracic artery grafting, the use of RGEA for revascularization of the right coronary system does not confer clinical benefits over SVG after midterm follow-up.

Reduced strokes in the elderly: the benefits of untouched aorta off-pump coronary surgery.

BACKGROUND: Avoiding aortic manipulation during off-pump coronary artery bypass (OPCAB) reduces the risk for atheroembolic complications and may, thus, benefit elderly patients who are prone to atherosclerotic aortic involvement. METHODS: During a period of 18 months (2000-2002), 160 consecutive OPCAB patients older than 75 years were evaluated. One hundred and three patients undergoing clampless OPCAB were compared to 57 patients in whom side clamps were applied. Clampless revascularization was achieved by in situ or T-graft arterial configurations. RESULTS: Mean age was older (79.3 years vs 78.2, p = 0.049) and the prevalence (43% vs 7%, p < 0.0001) and severity of aortic disease was higher in the clampless group. The main conduits used were bilateral skeletonized internal thoracic artery (47%) and radial arteries (42%). More grafts were performed in the side-clamp group (2.5 +/- 0.5 vs 2.3 +/- 0.6, p = 0.023), however, revascularization of the postero-lateral territory was comparable. While early mortality (2.9% vs 7%, p = >or=0.05), perioperative myocardial infarction (3% vs 5%, p = >or=0.05), and sternal infections (none) were similar, the incidence of major neurological complications (0% vs 5.3%, p = 0.044) and the combined outcome of stroke or mortality (3% vs 12%, p = 0.035) were lower in the clampless group. Multivariate analysis identified side clamping as a predictor for the occurrence of stroke or mortality (OR, 6.28, CL 1.39-28.4, p = 0.017), increasing this risk by sixfold. CONCLUSIONS: Clampless OPCAB is associated with reproducible neurological benefit. Improved neurological outcome may be conferred irrespective of the method of aortic screening in patients 75 years or older. The use of arterial conduits for this purpose is feasible despite the patients' advanced years.