A nationwide survey on perception, experience, and expectations of hybrid coronary revascularization among top-ranked US hospitals.

BACKGROUND: Hybrid coronary revascularization (HCR) combines a surgical and percutaneous approach for treatment of multivessel coronary artery disease. METHODS: A survey was conducted among 200 cardiologists and cardiac surgeons from 100 top-ranked US hospitals. Questions were asked involving the perception, experience, and future expectations of HCR. RESULTS: Of physicians invited to the survey, 90 completed the survey (45.5%). Relative to nonresponders, responders were more often affiliated with an academic institution (80.0% vs 61.8%, P=.005), with higher patient volumes, and with the availability of a hybrid operating room (90.0% vs 67.3%, P<.001). Survey responders felt that HCR should be considered in an older and relatively healthy patient population without complex lesions. Cardiac surgeons were more favorable to use HCR in patients with chronic lung disease (42.0% vs 10.0%, P<.001) or renal failure (28.0% vs 15.0%, P=.06). Among responders with HCR experience (n=54), 94% reported good to excellent results, and the learning curve differed depending on the surgical technique used. Inappropriate patient selection (41.2%) was the most common cause for complications. Three-quarter of responders believe that the future role for HCR will expand in the next decade. Important determinants of greater HCR use in the future were collaborative associations between cardiac surgeons and cardiologists (86.7%), appropriate patient selection (67.8%), and the outcomes of ongoing clinical trials (57.8%). CONCLUSION: In this nationwide survey, cardiologists and cardiac surgeons felt that HCR is a reasonable alternative technique for coronary revascularization among suitable patients. Most felt that use of HCR would increase in the next decade.

Simulation trainer for practicing emergent open thoracotomy procedures.

BACKGROUND: An emergent open thoracotomy (OT) is a high-risk, low-frequency procedure uniquely suited for simulation training. We developed a cost-effective Cardiothoracic (CT) Surgery trainer and assessed its potential for improving technical and interprofessional skills during an emergent simulated OT. MATERIALS AND METHODS: We modified a commercially available mannequin torso with artificial tissue models to create a custom CT Surgery trainer. The trainer's feasibility for simulating emergent OT was tested using a multidisciplinary CT team in three consecutive in situ simulations. Five discretely observable milestones were identified as requisite steps in carrying out an emergent OT; namely (1) diagnosis and declaration of a code situation, (2) arrival of the code cart, (3) arrival of the thoracotomy tray, (4) initiation of the thoracotomy incision, and (5) defibrillation of a simulated heart. The time required for a team to achieve each discrete step was measured by an independent observer over the course of each OT simulation trial and compared. RESULTS: Over the course of the three OT simulation trials conducted in the coronary care unit, there was an average reduction of 29.5% (P < 0.05) in the times required to achieve the five critical milestones. The time required to complete the whole OT procedure improved by 7 min and 31 s from the initial to the final trial-an overall improvement of 40%. CONCLUSIONS: In our preliminary evaluation, the CT Surgery trainer appears to be useful for improving team performance during a simulated emergent bedside OT in the coronary care unit.

Managing port-site bleeding during less invasive coronary artery bypass grafting.

INTRODUCTION: Robotic-assisted coronary artery bypass grafting (r-CABG) requires the placement of ports bluntly through the chest wall. When removed, these ports create bleeding sites that can be difficult to detect and treat. This study evaluated whether a topical hemostatic agent placed locally within these sites helps to reduce bleeding and blood product requirements. METHODS: We retrospectively analyzed outcomes for r-CABG cases where 5 mL of a flowable hemostatic agent was injected locally within all port sites (hemostat group, n = 62) compared with patients whose port sites were untreated (controls, n = 131). Outcomes included chest tube output, red blood cell (RBC) transfusions, length of hospital stay, and the risk of reoperation for bleeding. Analyses were adjusted for risk factors known to influence bleeding and Society of Thoracic Surgeons (STS) risk score as a weighted composite of variables, which controls for patient and clinical variables. RESULTS: The 2 study groups had similar baseline characteristics and underwent the same r-CABG procedure. The hemostat group had significant reductions in RBC transfusion (24.2% versus 40.8% receiving blood; P = .026; 0.44 versus 1.39 U transfused postoperatively, P = .024). After adjustment for bleeding risks (using STS risk score), differences in transfusions remained significant. Reoperation rates for bleeding, length of stay, chest tube drainage, and intraoperative transfusions were not significantly different in the 2 groups. CONCLUSIONS: There was significantly reduced postoperative bleeding and less exposure to blood products in the hemostat group. These findings suggest that undetected bleeding from sites used for port access serves as an underappreciated source of morbidity after r-CABG.

Coronary computed tomography angiography following robotic coronary artery bypass grafting surgery: Systematic approach to image analysis and practical considerations.

Standard open chest Coronary Artery Bypass Grafting (CABG) has evolved over last couple of decades. With advancement in minimally invasive procedures, Robotic CABG (RCABG) is still in its evolution phase. There is dearth of experienced surgeons in this complicated field and lack of data to verify it clinical safety. in this review, we intend to describe the utility of Cardiac Computed Tomography Angiography (CCTA) in assessment of graft anatomy and quality, grafting strategy, distal graft anastomosis site evaluation and detection of complications associated with RCABG. CCTA appears to provide valuable information regarding the visualization of grafts, target coronary arteries and other cardiac and non-cardiac structures.

OR and ICU teams 'running in parallel' at the end of cardiothoracic surgery improves perceptions of handoff safety.

The transfer of a cardiac surgery patient from the operating room (OR) to the intensive care unit (ICU) is both a challenging process and a critical period for outcomes. Information transferred between these two teams-known as the 'handoff'-has been a focus of efforts to improve patient safety. At our institution, staff have poor perceptions of handoff safety, as measured by low positive response rates to questions found in the Agency for Health Care Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS). In this quality improvement project, we developed a novel handoff protocol after cardiac surgery where we invited the ICU nurse and intensivist into the OR to receive a face-to-face handoff from the circulating nurse, observe the final 30 min of the case, and participate in the end-of-case debrief discussions. Our aim was to increase the positive response rates to handoff safety questions to meet or surpass the reported AHRQ national averages. We used plan, do, study, act cycles over the course of 123 surgical cases to test how our handoff protocol was leading to changes in perceptions of safety. After a 10-month period, we achieved our aim for four out of the five HSOPS questions assessing safety of handoff. Our results suggest that having an ICU team 'run in parallel' with the cardiac surgical team positively impacts safety culture.

A randomized clinical trial investigating the relationship between aprotinin and hypercoagulability in off-pump coronary surgery.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery is associated with a hypercoagulable state in which the platelet thrombin receptor, protease-activated receptor-1 (PAR-1), helps propagate a thrombin burst within saphenous vein grafts. Aprotinin, used in cardiothoracic surgery mainly for its antifibrinolytic properties, also spares platelet PAR-1 activation due to thrombin. We hypothesized that this PAR-1 antagonistic property provides an antithrombotic benefit during OPCAB surgery. METHODS: Patients were randomly assigned to receive saline (n = 38) or a modified full-dose regimen of aprotinin (n = 37) IV during OPCAB surgery. Blood sampled perioperatively from the coronary sinus, skin wounds, and systemic circulation was analyzed to test coagulation and platelet function. Major adverse cardiovascular events were monitored by obtaining troponin I at 24 h (myocardial infarction), predischarge computed tomography angiography (vein graft thrombosis), and by clinical examination for stroke. RESULTS: Coronary sinus blood obtained immediately after OPCAB surgery showed significantly less activation in the aprotinin group, as judged by reduced formation of platelet-leukocyte conjugates (P < 0.02) and platelet-derived microparticles (P < 0.05). The aprotinin group showed inhibition of platelet aggregation induced by thrombin (P = 0.007) but not adenosine diphosphate. Thrombin generation, defined by F1.2 levels, was significantly reduced by aprotinin in the coronary sinus but not in skin wound incisions. Major adverse cardiovascular events were significantly reduced in aprotinin-treated patients (5.4% vs 29.7%, P < 0.05). Aprotinin also demonstrated antifibrinolytic properties through diminished red blood cell transfusion (P < 0.04) and reduced blood loss postoperatively (603 +/- 330 vs 810 +/- 415 mL, P < 0.004). CONCLUSION: This study demonstrates that aprotinin protects patients undergoing OPCAB surgery from a hypercoagulable state by diminishing thrombin-induced platelet activation and thrombin generation within saphenous vein grafts, while maintaining systemic hemostatic and antifibrinolytic benefits. These results support further investigation of aprotinin and other PAR-1 antagonists in OPCAB surgery.

Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques.

BACKGROUND: Minimally invasive coronary artery bypass grafting (miniCABG) decreases in-hospital morbidity versus traditional sternotomy CABG. We performed a prospective cohort study (NCT00481806) to assess the impact of miniCABG on costs and metrics that influence quality of life after hospital discharge. METHODS: One hundred consecutive miniCABG cases performed using internal mammary artery (IMA) grafting +/- coronary stenting were compared with a matched group of 100 sternotomy CABG patients using IMA and saphenous veins, both treating equivalent number of target coronaries (2.7 vs. 2.9), off-pump. We compared perioperative costs, time to return to work/normal activity, and risk of major adverse cardiac/cerebrovascular events (MACCE) at 1 year: myocardial infarction (elevated troponin or EKG changes), target vessel occlusion (CT angiography at 1 year), stroke, or death. RESULTS: For miniCABG, robotic instruments and stents increased intraoperative costs; postoperative costs were decreased from significantly less intubation time (4.80 +/- 6.35 vs. 12.24 +/- 6.24 hours), hospital stay (3.77 +/- 1.51 vs. 6.38 +/- 2.23 days), and transfusion (0.16 +/- 0.37 vs. 1.37 +/- 1.35 U) leading to no significant differences in total costs. Undergoing miniCABG independently predicted earlier return to work after adjusting for confounders (t = -2.15; P = 0.04), whereas sternotomy CABG increased MACCE (HR, 3.9; 95% CI, 1.4-7.6), largely from lower target-vessel patency. CONCLUSIONS: MiniCABG shortens patient recovery time, minimizes MACCE risk at 1 year, and showed superior quality and outcome metrics versus standard-of-care CABG. These findings occurred without increasing costs and with superior target vessel graft patency.

Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes.

Surgical and percutaneous coronary artery intervention revascularization are traditionally considered isolated options. A simultaneous hybrid approach may allow an opportunity to match the best strategy for a particular anatomic lesion. Concerns regarding safety and feasibility of such an approach exist. We examined the safety, feasibility, and early outcomes of a simultaneous hybrid revascularization strategy (minimally invasive direct coronary bypass grafting of the left anterior descending [LAD] artery and drug-eluting stent [DES] to non-LAD lesions) in 13 patients with multivessel coronary artery disease that underwent left internal mammary artery to LAD minimally invasive direct coronary bypass performed through a lateral thoracotomy, followed by stenting of non-LAD lesions, in a fluoroscopy-equipped operating room. Assessment of coagulation parameters was also undertaken. Inhospital and postdischarge outcomes of these patients were compared to a group of 26 propensity score matched parallel controls that underwent standard off-pump coronary artery bypass. Baseline characteristics were similar in both groups. All hybrid patients were successfully treated with DES and no inhospital mortality occurred in either group. Hybrid patients had a shorter length of stay (3.6 +/- 1.5 vs 6.3 +/- 2.3 days, P < .0001) and intubation times (0.5 +/- 1.3 vs 11.7 +/- 9.6 hours, P < .02). Despite aggressive anticoagulation and confirmed platelet inhibition, hybrid patients had less blood loss (581 +/- 402 vs 1242 +/- 941 mL, P < .05) and decreased transfusions (0.33 +/- 0.49 vs 1.47 +/- 1.53 U, P < .01). Six-month angiographic vessel patency and major adverse cardiac events were similar in the hybrid and off-pump coronary artery bypass groups. A simultaneous hybrid approach consisting of minimally invasive coronary artery bypass grafting with left internal mammary artery to LAD combined with revascularization of the remaining coronary targets using percutaneous coronary artery intervention with DES is a feasible option accomplished with acceptable clinical outcomes without increased bleeding risk.

Preserving and evaluating hearts with ex vivo machine perfusion: an avenue to improve early graft performance and expand the donor pool.

Cardiac transplantation remains the first choice for the surgical treatment of end stage heart failure. An inadequate supply of donor grafts that meet existing criteria has limited the application of this therapy to suitable candidates and increased interest in extended criteria donors. Although cold storage (CS) is a time-tested method for the preservation of hearts during the ex vivo transport interval, its disadvantages are highlighted in hearts from the extended criteria donor. In contrast, transport of high-risk hearts using hypothermic machine perfusion (MP) provides continuous support of aerobic metabolism and ongoing washout of metabolic byproducts. Perhaps more importantly, monitoring the organ's response to this intervention provides insight into the viability of a heart initially deemed as extended criteria. Obviously, ex vivo MP introduces challenges, such as ensuring homogeneous tissue perfusion and avoiding myocardial edema. Though numerous groups have experimented with this technology, the best perfusate and perfusion parameters needed to achieve optimal results remain unclear. In the present review, we outline the benefits of ex vivo MP with particular attention to how the challenges can be addressed in order to achieve the most consistent results in a large animal model of the ideal heart donor. We provide evidence that MP can be used to resuscitate and evaluate hearts from animal and human extended criteria donors, including the non-heart beating donor, which we feel is the most compelling argument for why this technology is likely to impact the donor pool.

Warm ischemia provokes inflammation and regional hypercoagulability within the heart during off-pump coronary artery bypass: a possible target for serine protease inhibition.

OBJECTIVE: Accumulating evidence suggests that a hypercoagulable state influences early graft failure after off-pump coronary artery bypass (OPCAB). We hypothesized that regional myocardial ischemia caused by obligatory periods of coronary occlusion during OPCAB is an important trigger for this prothrombotic state. METHODS: Using a series of biomarkers, 60 consecutive patients undergoing OPCAB were monitored for myocardial injury (myoglobin), inflammation (TNF-alpha, IL-8) and thrombosis (thrombin generation-F1.2, contact activation pathway-FXII-a, platelet derived microparticles-via flow cytometry). The transcardiac gradients of these markers were determined by assaying both arterial and coronary sinus blood just after protamine administration. Intramyocardial pH was monitored continuously during coronary occlusion in a subset (N=30 grafts, 11 patients). The influence of management strategies affecting hemostasis (e.g. antiplatelet therapy, anti-fibrinolytics, peak activated clotting time (ACT) during heparinization) was analyzed. RESULTS: Ischemic injury, depicted by the transcardiac myoglobin gradient, significantly correlated with intramyocardial acidosis during coronary occlusion (R=0.96, p<0.0001) and predicted the transcardiac gradients of TNF-alpha (R=0.83, p<0.001) and F1.2 (R=0.72, p<0.0001). Transcardiac F1.2 strongly correlated with TNF-alpha (R=0.73, p=0.01) and IL-8 (R=0.51, p=0.02). Patients receiving aprotinin (N=20) showed significantly lower transcardiac gradients for myoglobin (4.1+/-7.5% vs 72.9+/-108.8% change, p=0.002), F1.2 (31+/-37% vs 89+/-149%, p=0.03), FXII-a (2.6+/-4.1% vs 19.2+/-34%, p=0.04) and microparticles (7+/-3.9% vs 12.9+/-8%, p=0.01). CONCLUSIONS: Strong correlations between myocardial ischemia and the transcardiac gradients of markers for inflammation and thrombosis suggest that even brief episodes of coronary occlusion in the beating heart may have pathophysiologic consequences. Aprotinin, but not other factors that influence the coagulation system, appears to mitigate this process during OPCAB.

Thinking inside the graft: applications of optical coherence tomography in coronary artery bypass grafting.

Recent advances in catheter-based optical coherence tomography (OCT) have provided the necessary resolution and acquisition speed for high-quality intravascular imaging. Complications associated with clearing blood from the vessel of a living patient have prevented its wider acceptance. We identify a surgical application that takes advantage of the vascular imaging powers of OCT but that circumvents the difficulties. Coronary artery bypass grafting (CABG) is the most commonly performed major surgery in America. A critical determinant of its outcome has been postulated to be injury to the conduit vessel incurred during the harvesting procedure or pathology preexistent in the harvested vessel. As a test of feasibility, intravascular OCT imaging is obtained from the radial arteries (RAs) and/or saphenous veins (SVs) of 35 patients scheduled for CABG. Pathologies detected by OCT are compared to registered histological sections obtained from discarded segments of each graft. OCT reliably detects atherosclerotic lesions in the RAs and discerns plaque morphology as fibrous, fibrocalcific, or fibroatheromatous. OCT is also used to assess intimal trauma and residual thrombi related to endoscopic harvest and the quality of the distal anastomosis. We demonstrate the feasibility of OCT imaging as an intraoperative tool to select conduit vessels for CABG.

Coronary artery bypass grafts: assessment with multidetector CT in the early and late postoperative settings.

Coronary artery bypass graft (CABG) surgery is the standard of care in the treatment of advanced coronary artery disease. It is well known that the long-term clinical outcome after myocardial revascularization depends on the patency of the bypass grafts. In the past, invasive coronary angiography was used to assess the status of the grafts and check for graft occlusion. Recently, computed tomography (CT), particularly multidetector CT with electrocardiographic gating, has emerged as an important diagnostic tool for evaluation of CABGs in both the early (< or =1 month) and late (>1 month) postoperative settings. A variety of postoperative complications may manifest as dyspnea and chest pain, thereby mimicking recurrent angina secondary to graft occlusion. Owing to its improved spatial resolution compared with that of earlier-generation CT scanners and its ability to produce three-dimensional and multiplanar images, multidetector CT has assumed an integral role in characterization of graft patency while allowing investigation of alternative postoperative complications. In addition, the expanded capabilities of volumetric imaging may provide valuable information in preoperative planning for repeat CABG surgery.

LVAD bloodstream infections: therapeutic rationale for transplantation after LVAD infection.

INTRODUCTION: Patients who have ventricular assist devices (VADs) and experience bloodstream infection (BSI) have high mortality. We addressed 2 questions raised by the United Network for Organ Sharing (UNOS) priority policy for this problem: 1) Are organs wasted on this ultra-high-risk group? 2) Can device-related BSI be differentiated from transient BSI? METHODS: Patients with VADs who underwent heart transplantation from 1987 to 2001, who had BSI during VAD support, and who had positive cultures at VAD explant (device-related BSI, n = 10) were compared with those with negative cultures at explant (non-device-related BSI, n = 11). RESULTS: Patients with device-related BSI had an 80% (8/10) rate of persistent bacteremia; 30 days and 1 year after transplantation, mortality was 14% and 26%, respectively. Non-device-related BSI (n = 11) persisted in 18% (2/11); peri-operative and 1-year mortalities were 9% and 13%. Duration of VAD support predicted infection (132 vs 48 days, p < 0.001); hypo-albuminemia (2.9 +/- 0.5 mg/dl vs 3.3 +/- 0.8 mg/dl, p < 0.05), and a resistant organism predicted a device-related BSI. These patients had increased intubation requirements and had increased creatinine concentration during the first post-operative week, with no difference in liver function, blood loss, transfusions (packed red blood cells, fresh frozen plasma, or platelets), or hemodynamic stability vs patients with non-device BSI. Despite decreased immunosuppression, we found no difference in acute rejection events with device-related BSI. Re-infection with the pre-operative organism occurred in only 1 patient per group. CONCLUSIONS: These data suggest that urgent (Status 1A) cardiac transplantation is effective in stable patients with device-related BSI, and these data support the current UNOS policy. However, an extra-device source of BSI should be excluded by considering the isolated organism, the baseline nutritional status, and other risk factors.

Myocardial reperfusion injury: etiology, mechanisms, and therapies.

Reperfusion of ischemic myocardium is required for tissue survival; however, reperfusion elicits pathologic consequences. Myocardial reperfusion injury is a multifarious process that is mediated in part by oxygen free radicals, neutrophil-endothelium interactions, apoptosis, and intracellular calcium overload. The oxygen paradox describes the contradictory need to delivery oxygen to ischemic tissue and the resultant reduction of oxygen to form free radicals that are involved in macromolecule oxidation, membrane disfunction, apoptosis, and damaged calcium sequestering ability, which results in hypercontracture. These cell-damaging crises are amplified by the excessive activation of neutrophils, which promote the formation of proinflammatory mediators, oxygen radicals, and the reduction of endothelial nitric oxide formation, leading to increased neutrophil-endothelium interactions and capillary occlusion. Neutrophil action is twofold, however, because it is required for necrotic debris removal after severe ischemia. The oxygen radicals produced by neutrophils, endothelium, and myocytes may also play a role in activating the apoptotic cascade. Although the role of apoptosis in reperfusion injury is controversial, apoptotic cells are found in infarcted tissue. One of the key mediators may be increased inner mitochondrial membrane permeability, resulting in reduced ATP formation, release of cytochrome c, and caspase activation, which is key to promotion of apoptosis. Increased mitochondrial membrane permeability occurs during exposure to supraphysiological calcium concentrations. This occurs because of compensatory Na+/Ca2+ exchange to remove the excess intracellular sodium resulting from decreased Na+/K+ pumping during ischemia and increased Na+/H+ exchange following reperfusion. Supraphysiological calcium elicits hypercontracture and cellular damage. The various therapies being developed to diminish myocardial reperfusion injury involve inhibition of the processes described above as well as others. Although single therapies have shown some promise, the complexity of the response to reperfusion has made dramatic improvement elusive. Effective treatment will most likely require multifaceted antagonism of the numerous pathological cascades initiated by reperfusion.

Transfusion outcomes in patients undergoing coronary artery bypass grafting treated with prasugrel or clopidogrel: TRITON-TIMI 38 retrospective data analysis.

OBJECTIVE: Coronary artery bypass grafting-related bleeding and associated transfusion is a concern with dual antiplatelet therapy in patients with acute coronary syndromes. The objective of the present study was to characterize a potential risk-adjusted difference in transfusion requirements between prasugrel and clopidogrel cohorts. METHODS: The data from 422 patients undergoing isolated coronary artery bypass grafting from the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 were analyzed retrospectively. RESULTS: We found no difference in baseline transfusion risk scores between cohorts. As predicted, the number of units of red blood cells transfused perioperatively correlated with the transfusion risk score (P < .0001). Overall, the 12-hour chest tube drainage volumes and platelet transfusion rates in the prasugrel cohort were significantly greater. However, no statistically significant differences were found in the number of red blood cell transfusions, total hemostatic components transfused, or total blood donor exposure. A significantly greater number of platelet units were transfused postoperatively in the prasugrel patients who underwent surgery within 5 days or less after withdrawal of drug. In an analysis adjusted for the predicted risk of mortality, total donor exposure was not associated with increased mortality. CONCLUSIONS: The use of prasugrel compared with clopidogrel was associated with greater 12-hour chest tube drainage volumes and platelet transfusion rates but without any significant differences in red blood cell transfusions, total hemostatic components transfused, or total blood donor exposure.

Endoscopic venous harvesting by inexperienced operators compromises venous graft remodeling.

BACKGROUND: Endoscopic vein harvesting (EVH) is the standard of care for coronary artery bypass grafting (CABG) in the United States, but recent comparisons with open harvesting suggest that conduit quality and outcomes may be compromised in EVH. To test the hypothesis that problems with EVH may relate to its learning curve and conduit quality, we analyzed the quality and early function of conduits procured by technicians with varying experience in EVH. METHODS: Experienced (more than 900 cases, n=55 patients) and novice (less than 100 cases, n=30 patients) technicians performed EVH during CABG. Subsequently, optical coherence tomography (OCT) was used to examine the conduits for vascular injury, with segments identified as injured being further examined for gene expression with an array of genes related to tissue injury. Conduit diameter was measured intra- and postoperatively (day 5 and 6 months, respectively) with OCT and computed tomographic angiography. RESULTS: Endoscopic vein harvesting by novice harvesters resulted in a greater number of discrete graft injuries and greater expression of tissue-injury genes than EVH done by experienced harvesters. Regression analysis revealed an association between shear stress and early dilation of engrafted vessels (positive remodeling) (R2=0.48, p<0.01). Injured veins showed blunted positive remodeling at 5 days after harvesting and a greater degree of late lumen loss at 6 months. CONCLUSIONS: Under normal conditions, intraluminal shear stress leads to positive remodeling of vein grafts during the first postoperative week. Injury to conduits, a frequent sequela of the learning curve for EVH, was a predictor of early graft failure and of blunted positive remodeling and greater negative remodeling of endoscopically harvested vein grafts. Given the current annual volume of cases in which EVH is used, rigorous monitoring of the learning curve for this procedure represents an important and unrecognized issue in public health.

Risk of renal dysfunction after less invasive multivessel coronary artery bypass grafting.

OBJECTIVE: Several centers have established that off-pump, multivessel coronary artery bypass grafting performed via a small thoracotomy (MVST) is feasible. However, this procedure can be challenging when posterolateral coronary targets need to be grafted. We hypothesized that use of cardiopulmonary bypass via peripheral access (MVST-PA) would improve outcomes compared with a completely off-pump approach (OP-MVST). METHODS: This was a prospective observational study of patients undergoing OP-MVST (n = 46) versus MVST-PA (n = 45) using bilateral internal mammary artery grafts onto the left anterior descending coronary artery and circumflex/right coronary artery distribution. Hemostasis was quantified by measuring platelet function (aggregometry), chest tube output, thrombolysis in myocardial infarction bleeding score (%hematocrit change at 24 hours), and transfusion requirements. The rate of mortality and major morbidity at 30 days was defined according to The Society of Thoracic Surgeons criteria. Estimated glomerular filtration rate (normalized to baseline levels) was determined daily until discharge. RESULTS: The OP-MVST versus MVST-PA groups had similar risk factors at baseline and risks of composite morbidity/mortality at 30 days. However, renal failure was significantly increased after OP-MVST (10.87 vs 0%, P = 0.05), and MVST-PA affected hemostasis as evidenced by inhibition of platelet function (latency to response on aggregometry, 29.9 vs 17.9 seconds; P = 0.04) and higher transfusion requirement (2.31 vs 0.85 units of red blood cells/patient, P = 0.04; 55.6% vs 34.8% transfused; P = 0.059). However, 24-hour chest tube output was similar (645 vs 750 mL; P = 0.53). CONCLUSIONS: In comparison with a completely off-pump strategy, use of cardiopulmonary bypass to assist MVST reduced the risk of renal dysfunction with only modest tradeoffs in other morbidities, for example, altered coagulation and higher transfusion requirements. These data justify further study of the effect of MVST-PA on renal complications.