Exclusive Bilateral Internal Thoracic Artery Grafts for Myocardial Revascularization Requiring Four Anastomoses or More: Outcomes from a Single Center Experience.

Introduction Multivessel coronary artery bypass graft (CABG) with bilateral internal thoracic arteries (BITA) has only been uncommon and technically demanding. We describe our experience with BITA only CABGs requiring ≥ 4 anastomoses. Material and Methods The department's database was queried for patients undergoing isolated CABG with ≥ 4 anastomoses. The surgical technique included systematically a right internal thoracic artery (ITA) of left ITA Y graft. The multivariate model included variables with a p < 0.3 at univariate analysis. Results Between January 2006 and December 2009, 251 consecutive patients (71 ± 10 years) (on-pump: 130, off-pump: 121) had CABG with ≥ 4 anastomoses, representing 21% of total isolated CABGs for the same period; all patients received a totally arterial BITA only revascularization. Follow-up was 4.9 ± 1.6 years. Overall and cardiac cumulative survivals were 78 and 92%, respectively, at 5 years. The occurrence of any major postoperative complication was associated with overall and cardiac mortality (odds ratio [OR]: 3.6, 95% confidence interval [CI]: 1.3-9.9 and OR: 5.4, 95% CI: 1.3-21.9, respectively). Major sternal wound complication requiring surgical revision was not associated with impaired glucose control (n = 9; diabetics: 6/82, 7.3%; nondiabetics: 3/169, 1.8%, p = 0.06). Preoperative kidney failure was associated with incomplete revascularization (OR: 6.2; 95% CI: 1.2-33.5), that was unfailingly due to ungraftable right coronary artery targets. Discussion BITA only revascularization was a valuable and safe procedure, with favorable results in terms of morbidity and mortality at a 5 years' follow-up.

Relationship between depression and health-related quality of life in patients undergoing coronary artery bypass grafting: a MOTIV-CABG substudy.

CONTEXT/OBJECTIVES: Depression is associated with higher risk of death and major adverse cardiac events among patients undergoing coronary artery bypass grafting (CABG). This study aimed to investigate the impact of preoperative depression on health-related quality of life (HRQoL) changes over the first 12 postoperative months. METHODS: Patients were the participants in the MOTIV-CABG study that was a single-center, non-stratified, randomized, double-blind, parallel-group, phase 4 trial, conducted between January 2006 and February 2012 at University Hospital, Besançon, France. The effect of preoperative depression (measured using the Beck Depression Inventory, BDI) on changes in SF-36 component summary scores [mental (MCS) and physical (PCS)] over time was tested using a generalized linear model for repeated measures. The presence of depression was defined as a BDI score >3. RESULTS: There were 359 patients in this study: 217 (60.4 %) had no preoperative depression, and 142 (39.6 %) had preoperative depression. During follow-up, the MCS and PCS scores increased in both groups. The improvement was of smaller magnitude in the group of patients depressed baseline as compared to those with no depression (difference in LSM = -7.45, p < 10(-3), for MCS, and -6.80, p < 10(-3), for PCS). CONCLUSION: Preoperative depression has a negative impact on HRQoL improvement during postoperative follow-up after CABG. It seems important to detect depression before CABG to begin antidepressant therapy and improve patients' HRQoL.

Early detection of asymptomatic bypass graft abnormalities using a cardiac troponin I ratio following coronary artery bypass surgery.

BACKGROUND: We sought to identify the best cardiac Troponin I (cTnI) ratio to detect asymptomatic graft or anastomoses anomalies after myocardial revascularization. METHODS: Patients with a rising cTnI profile, based on measurements at 6 and 12 hours (cTnI 12 hours : 6 hours ratio >1) after the last anastomosis in off-pump surgery or after cardiopulmonary bypass in on-pump surgery, underwent a coronary angiogram, despite an uncomplicated postoperative course and absence of electrocardiogram changes. The optimal threshold value for the ratio was determined using a receiving operator characteristic (ROC) curve. RESULTS: From April 2005 to May 2011, among 1693 patients undergoing isolated coronary artery bypass graft (CABG), 29 (1.7%) had a cTnI ratio >1 and underwent postoperative angiography. Twenty abnormalities were observed in 16 patients (55%). In the anastomoses, there were four occlusions and four stenosis. In the grafts, there were 12 stenosis: two of the Y graft anastomosis, two dissections, five hematomas and three kinking. TIMI flow grade based on results of the Thrombolysis In Myocardial Infarction trial was 3 in six patients, 1 in five, and 0 in five. In the 16 patients with lesions, the cTnI ratio was 2.1 ± 1.4 versus 1.4 ± 0.3 in patients with no lesions (p = 0.09). A ratio of 1.3 (p = 0.003) was determined by ROC curve analysis as having the greatest discriminant capacity, with associated sensitivity of 87.5% and specificity of 62%. CONCLUSION: A cTnI 12 hours : 6 hours ratio >1.3 may be indicative of these abnormalities. Early identification of these anomalies may avoid adverse outcomes.

Six-year outcomes after non-resective mitral valve repair with artificial chordae using removable clips.

BACKGROUND AND AIM OF THE STUDY: The results were evaluated of a non-resective technique for mitral valve repair with artificial chordae implantation that allows modification of the length of the chordae as many times as necessary, and avoids inadvertent alteration of chordal length during fixation by using removable clips. METHODS: After having determined the length of the artificial chordae, a removable clip was tied on the two thread ends to prevent sliding when performing the competence test. The length of the artificial chordae could be modified by opening the clip and closing it elsewhere along the chordae length. When the competence test was satisfactory, the threads were knotted on the clips. Long-term follow up was completed between January and May 2012, by echocardiography plus consultation with a cardiologist at the authors' institution. RESULTS: A total of 47 patients underwent repair with this technique. Follow up was complete at a median of 6.0 years. There were no in-hospital deaths, but four deaths occurred during the follow up period (8.5%). The survival rate at six years was 91.5 +/- 2.1%. One patient (2.1%) had recurrent mitral regurgitation (MR) and required reoperation within two years after the initial surgery. The event-free survival rate, defined as survival free from death, reoperation or cardiovascular adverse events, was 87.2 +/- 5.2% at six years. At the time of follow up, echocardiography identified a fully competent valve or minimal MR in 45 patients (96%), mild MR in one patient (2.1%), and significant MR in one patient (2.1%). CONCLUSION: A satisfactory six-year outcome is reported for this method, whereby removable clips were used to determine the correct length of the artificial chordae, and for accurate tying of the knots.

Neutrophil gelatinase-associated lipocalin as early predictor of acute kidney injury after cardiac surgery in adults with chronic kidney failure.

BACKGROUND: To assess the utility of neutrophil gelatinase-associated lipocalin (NGAL) as an early marker of acute kidney injury (AKI) occurring after cardiac surgery in patients with prior chronic kidney failure. METHODS: Patients with preoperative creatinine clearance 60 mL • min(-1) • 1.73 m(-2) or less according to the Cockcroft-Gault formula and scheduled to undergo cardiac surgery were eligible for inclusion. The AKI was defined as an increase in plasma creatinine greater than 50% over preoperative values. Threshold values of NGAL predictive of AKI were determined using receiver operating characteristic curve analysis, and predictive value of NGAL for AKI was evaluated by logistic regression. RESULTS: Over a 1-year inclusion period, 166 patients were included. At 6 hours post-surgery, hypertension, occurrence of at least 1 postoperative complication, and NGAL greater than 155 ng/mL were shown to be independent predictors of AKI. NGAL greater than 155 ng/mL at 6 hours was associated with an odds ratio for risk of postoperative AKI of 7.1 [2.7 to 18]. On average, diagnosis of postoperative AKI was made 20 hours earlier using NGAL at 6 hours post-surgery as compared with a diagnosis based on a 50% increase in creatinine over baseline. The threshold for NGAL of 155 ng/mL at 6 hours had a sensitivity of 79% and specificity of 58% for the diagnosis of AKI. CONCLUSIONS: Earlier diagnosis of AKI post-surgery based on NGAL assessment makes it possible to initiate appropriate therapy at an earlier stage in this high-risk patient population.

Left ventricular venting through the right subclavian artery access during peripheral extracorporeal life support.

The use of peripheral extracorporeal life support during refractory cardiac arrest sometimes exposes the patient to left ventricular dilatation requiring venting. We report here a simple technique for LV venting by a cannula inserted through right subclavian artery and positioned in the left ventricle.

Antidepressant therapy in patients undergoing coronary artery bypass grafting: the MOTIV-CABG trial.

BACKGROUND: The efficacy of antidepressant therapy in patients undergoing coronary artery bypass grafting (CABG) is not clearly established. METHODS: This double-blind trial was conducted at University Hospital, Besançon, France. Adult CABG patients were randomized (1:1) to receive escitalopram (10 mg daily) or placebo from 2 to 3 weeks before to 6 months after surgery, including 12 months post-surgery follow-up. The primary composite endpoint was the occurrence of mortality or predefined morbidity events. Secondary endpoints included measures of depression, mental and physical health using Beck Depression Inventory Short Form (BDI), and quality of life 36-Item Short Form (SF-36) self assessments. RESULTS: The treated cohort contained 361 patients with mean age 67 years. At 12 months, the proportions of patients with the composite morbidity and mortality endpoint were not different between escitalopram and placebo (110 of 182 [60.4%] vs 108 of 179 [60.3%], p = 0.984). However, over the 6 months postoperative period, the BDI and SF-36 Mental Component Summary scores were better overall in the escitalopram group than in the placebo group for all patients (p = 0.015 and p = 0.014, respectively) and preoperatively depressed (BDI > 3) patients (p = 0.002 and p = 0.005, respectively). Moreover, the SF-36 Pain score was better overall in the escitalopram group than in the placebo group in the preoperatively-depressed subset (p = 0.026). CONCLUSIONS: Antidepressant therapy had no effect on morbidity and mortality events up to 1 year after CABG. However, antidepressant therapy may provide faster improvements to mental health aspects of quality of life and reduce postoperative pain in patients with preoperative depression. Subject to contra-indications, we recommend antidepressant therapy in coronary revascularization patients who are preoperatively depressed.

Presence of circulating endothelial progenitor cells and levels of stromal-derived factor-1α are associated with ascending aorta aneurysm size.

OBJECTIVE: Circulating endothelial progenitor cells (EPCs) are a specialized subset of stem/progenitor cells found in bone marrow. They participate in neo-vascularization of injured vessels and predict cardiovascular outcome in patient at risk. Several factors influence their migration and proliferation, among which is the widely studied stromal-derived factor-1α (SDF-1α). In cardiovascular disease, regarding thoracic aortic aneurysms (TAAs), few studies have investigated the levels of EPC and SDF-1α. As rupture, acute dissection and hematoma are acute complications of idiopathic ascending thoracic aortic aneurysm (iATAA) that increase with the size of aneurysm, we aimed to evaluate a potential relationship between circulating EPC and SDF-1α and iATAA size. METHODS: The aneurysm size of 27 consecutive patients suffering from iATAA and scheduled for surgery was assessed by computed tomography scan. In all patients, we measured levels of circulating EPCs by flow cytometer, and plasma levels of SDF-1α the day before surgery. RESULTS: The median aneurysm size was 54 mm (interquartile range (IQR): 50.0-58.8]. The EPC levels of CD34+/CD144+/CD14- and CD34+/VEGF-R2+/CD14- were inversely correlated to aneurysm diameter (p = 0.038, r = -0.424 and p = 0.0046, r = -0.65, respectively) before surgery. Conversely, plasma levels of SDF-1α were positively correlated to aneurysm size (p = 0.042; r = 0.47). CONCLUSIONS: Our findings indicate that EPC levels may be useful for monitoring ascending aorta aneurysms and that SDF-1α could be a biomarker of iATAA expansion.