Can we perform coronary artery bypass grafting on the basis of computed tomographic angiography alone? A comparison with conventional coronary angiography.

OBJECTIVES: Multislice (64 slice) computed tomography (MSCT) angiography has recently emerged as a potential technique that can evaluate the coronaries in an accurate yet non-invasive manner. It has still not been shown whether the accuracy of the anatomy shown is precise enough to operate on the basis of MSCT alone. The aim of this prospective clinical trial is to compare MSCT to conventional coronary angiography (CCA), and to conclude whether MSCT alone is adequate for proceeding for CABG. METHODS: 50 patients with proven severe coronary artery disease (CAD) on CCA for elective CABG underwent MSCT prior to CABG. The MSCT images were compared with CCA and the accuracy, sensitivity and specificity of detecting significant stenosis cross checked. Lesion-by-lesion analysis was made. CCA was used as the reference standard for location and degree of stenosis. RESULTS: An excellent correlation was found between the CCA and MSCT findings. The overall sensitivity, specificity, positive (PPV) and negative (NPV) predictive values for quantitative assessment of stenosis >70% by MSCT compared to CCA were 98.5, 99.1, 82.3 and 99.8%, respectively. Comparing the maximal percent diameter luminal stenosis by MSCT versus CCA, the Pearson's correlation coefficient between the two modalities was 0.994 (p<0.0001). Bland-Altman analysis demonstrated a mean difference in percent stenosis of 0.05+/-2.42% (p=0.753). There was no significant correlation between stenosis difference and stenosis severity (Pearson's correlation coefficient=-0.027, p=0.695). 192 out of 207 (92.8%) of the observations were within +/-1.96 SD (4.8 to -4.7% stenosis difference). CONCLUSIONS: The improved spatial and temporal resolution of the 64 row scanner provides an excellent correlation of MSCT with CCA. MSCT is a valuable tool in the armamentarium of the cardiac scientist. For the cardiac surgeon performing off pump CABG it helps in precise planning of the procedure and pre-judging the length of the conduit required. On the basis of our findings, in selected patients, we recommend the consideration of MSCT as a sole criteria for proceeding for CABG without CCA.

Innovative hybrid procedure for dissection thoracic aorta in a patient with a previous bentall operation.

AIMS AND OBJECTIVES: In dissection aorta involving the whole aorta from the left subclavian artery surgical repair may be a high risk procedure while an endovascular procedure would not be feasible by itself in view of the absence of a safe landing zone and the risk of blocking the brain and arm circulation. A hybrid procedure is presented to tackle such a problem. METHODS: A 42-year-old Marfan, with a previous history of a Bentall procedure 10 years back, presented with acute thoracic aortic dissection. Investigations revealed a large dissection starting from the left subclavian to the right renal artery. Since a safe landing zone was required which would block off the arch vessels, first a redo sternotomy was performed and under femoro-femoral cardio-pulmonary bypass (CPB), a short segment of Dacron graft was interposed between the previous Bentall graft and the arch of aorta. On to this graft, 2 additional grafts were anastomosed. A 14 X 9 bifurcated graft to go to the right brachiocephalic and the left common carotid, and a 9 mm side arm to facilitate the positioning of the endograft. After coming off CPB, a guide wire was manipulated from the femoral artery into the side graft with a snare and the endograft was inserted. RESULTS: The false lumen was successfully obliterated. The patient made a complete recovery with no neurological deficit. CONCLUSIONS: A hybrid procedure with an innovative technique of preserving the brain and arm circulation and a new technique of facilitating proper positioning of the endostent with a side arm conduit is presented.

Bleeding risk of dietary supplements: A hidden nightmare for cardiac surgeons.

We report a 55-year-old man who underwent off-pump bypass surgery and had diffuse oozing and bruising postoperatively. His hematological profile had been normal preoperatively and he had been off antiplatelets for a week prior to surgery. Postoperatively, a detailed talk revealed that he had been on dietary supplements containing fish oil and garlic - both of which are known to affect platelet function. It behooves the surgeon and anesthetist to screen all patients preoperatively for the possibility of intake of any dietary supplements taken by the patient.

Malignant peripheral nerve sheath tumor of the anterior mediastinum: a rare presentation.

Malignant peripheral nerve sheath tumor (MPNST) is a rare tumor that accounts for 5% of all thoracic neoplasm usually located in the posterior mediastinum and is generally associated with a poor outcome. We present a case of MPNST of the anterior mediastinum presenting in a rare location leading to diagnostic dilemmas and treated primarily by surgical resection.