Coronary artery bypass grafting in left ventricular dysfunction: when and how.

PURPOSE OF REVIEW: The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients. RECENT FINDINGS: CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG. SUMMARY: Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient.

Paediatric cardiac surgery in a peripheral European region: is a joint programme a safe alternative to regionalisation?

BACKGROUND: In 2007, a partnership was initiated between a small-volume paediatric cardiac surgery unit located in Las Palmas de Gran Canaria, Spain, and a large-volume cardiac surgery unit located in Milan, Italy. The main goal of this partnership was to provide surgical treatment to children with CHD in the Canary Islands. METHODS: An operative algorithm for performing surgery in elective, urgent, and emergency cases was adopted by the this joint programme. Demographic and in-hospital variables were collected from the medical records of all the patients who had undergone surgical intervention for CHD from January, 2009 to March, 2013. Data were introduced into the congenital database of the European Congenital Heart Surgeons Association Congenital Database and the database was interrogated. RESULTS: In total, 65 surgical mission trips were performed during the period of this study. The European Congenital Heart Surgeons Association Congenital Database documented 214 total patients with a mean age at operation of 36.45 months, 316 procedures in total with 198 cardiopulmonary bypass cases, 46 non-cardiopulmonary bypass cases, 26 cardiovascular cases without cardiopulmonary bypass, 22 miscellaneous other types of cases, 16 interventional cardiology cases, six thoracic cases, one non-cardiac, non-thoracic procedure on a cardiac patient with cardiac anaesthesia, and one extracorporeal membrane oxygenation case. The 30-day mortality was 6.07% (13 patients). CONCLUSIONS: A joint programme between a small-volume centre and a large-volume centre may represent a valid and reproducible model for safe paediatric cardiac surgery in the context of a peripheral region.

Coronary Artery Surgery: Past, Present, and Future.

Coronary artery bypass grafting (CABG) is the most commonly performed and studied major cardiac operation worldwide. An understanding of the evolution of CABG, including the early days of cardiac surgery, the first bypass operation, continuous improvements in techniques, and streamlining of the operation, is important to inform current trends and future innovations. This article will examine how CABG evolved (from techniques to conduits), describe current trends in the field, and explore what lies on the horizon for the future of CABG.

Intracaval Leiomyoma with Intracardiac Extension.

The objective of this study was to explain step by step how to achieve a complete resection of an intravascular leiomyoma. A 48-year-old woman was referred to our institution with progressive dyspnea on exertion, lightheadedness, and previous history of total abdominal hysterectomy and bilateral salpingo-oophorectomy for a uterine leiomyoma echocardiography, computed tomography, and magnetic resonance imaging of the heart and abdomen/pelvis were performed and an intracaval mass with extension into the right heart and pulmonary artery was identified. After multidisciplinary review, a single-stage sternotomy-laparotomy procedure on cardiopulmonary bypass (with beating heart, mild hypothermia, and no deep hypothermic circulatory arrest) ensured complete resection of a giant intravenous leiomyoma (IVL). Multidisciplinary approach, multimodality imaging, and single-stage sternotomy-laparotomy procedure on cardiopulmonary bypass (with heart beating and mild hypothermia) ensure complete resection of IVL.

Surgery for Aneurysmal Coronary Artery Fistulas to the Coronary Sinus in Adults: A Case Series.

Surgical treatment of aneurysmal distal congenital coronary artery fistulas depends on size and anatomy. From 2008 to 2021, we applied a new surgical technique in 7 adult patients: proximal and distal fistula closure, opening of aneurysmal artery, and revascularization of branches rising from the fistula under cardiopulmonary bypass and cardiac arrest. (Level of Difficulty: Intermediate.).

Radical pericardiectomy for pericardial diseases.

Pericarditis is the most common form of pericardial disease. Its exact incidence remains unknown, probably because many cases resolve without diagnosis. Indications for pericardiectomy from the standpoint of the cardiac surgeon are based mainly on the physiopathology of 2 different entities that can overlap: inflammatory or relapsing pericarditis and constrictive pericarditis. Surgical indications are not always straightforward. Patients with inflammatory or relapsing pericarditis may undergo radical pericardiectomy because they experience severe symptoms despite maximal medical treatment or have sequelae from the medical treatment. Pericardiectomy is the standard treatment in patients with chronic constrictive pericarditis and persistent symptoms who are in New York Heart Association functional class III or IV and a class I recommendation in the European Society of Cardiology/European Association of Cardio-Vascular Surgery guidelines. The goal of surgery is always complete removal of any site of inflammation through a radical pericardiectomy.

Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease.

The debate over coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with stent placement for the treatment of stable multivessel coronary artery disease (CAD) continues in spite of numerous studies investigating the issue. This paper reviews the most recent randomized control trials (RCT) and meta-analyses of pooled RCT data to help address this issue. General trends demonstrated that CABG was superior in all-cause mortality and fulfilling the need for repeat revascularization. These advantages tended to be more pronounced in multivessel CAD and diabetes, and less so in left main CAD. PCI showed a consistently lower rate of cerebrovascular events. CABG continues to offer significant advantages over PCI, even as drug-eluting stent technology continues to evolve. The ideal endpoint for comparing PCI and CABG remains to be determined. Furthermore, additional research is required to further refine patient selection criteria for each intervention.

Fontan operation for patients with complex anatomy: the intra-atrial conduit technique.

The extracardiac conduit type of total cavopulmonary connection (TCPC) is the most common variation of the modified Fontan operation in current use. For patients with some forms of complex anatomy (eg, dextrocardia in situs solitus or asplenia syndrome), we have adopted a different technique: interposition of an intra-atrial conduit between the inferior vena cava (IVC) and the superior vena cava-right pulmonary artery (SVC-RPA) connection. We report our experience with six patients.

Intrapericardial teratoma in a low birth weight preterm infant: a successful multidisciplinary approach.

We report the case of an intrapericardial teratoma, a rare tumour in infants, prenatally diagnosed and successfully treated thanks to a multidisciplinary approach. An intrapericardial cystic mass (2.5 cm) with pericardial effusion was identified in a foetus at 32 weeks gestational age (GA). Intrauterine pericardiocentesis was performed immediately (40 ml) and repeated at 33 weeks (25 ml) and then at 34 weeks GA, just before birth (36 ml). Considering the rapid growth of the mass and the risk of hydrops, vaginal delivery was induced. A baby girl weighing 1.98 kg was born without cardiorespiratory compromise. Echocardiography and thoracic CT-scan located the 4.0×3.0 cm cystic mass between the left atrial appendage and the left superior pulmonary vein. At three days of life, the mass was completely removed without cardiobypass. It arose from the ascending aorta. Postoperative course was uneventful. Pathology diagnosed an immature intrapericardial teratoma. As long-term follow-up is required, alpha-fetoprotein can be a valid tool to monitor a possible recurrence. A multidisciplinary approach allows successful prenatal management and postnatal tumour surgery.