Reconstruction of a left main coronary artery aneurysm using a radial artery patch.

A left main coronary artery aneurysm is a rare anomaly. There are no standardized treatment guidelines given the infrequency of reported cases. A 70-year-old African American female with an enlarging distal left main coronary artery aneurysm was taken to the operating room for surgical intervention. The patient underwent a successful open surgical repair of the aneurysm with reconstruction of the distal left main using a radial artery patch. No coronary bypasses were necessary. Aneurysm ligation with concomitant coronary artery bypass grafting is commonly reported but reconstruction may be preferable when the anatomy is suitable. Preservation of nonobstructed native coronary artery circulation should also be considered to avoid life-long graft dependency.

Iliac vein stent migration with extensive cardiac damage in a patient with May-Thurner syndrome.

In May-Thurner syndrome, or iliac vein compression syndrome, the left common iliac vein is compressed between the right common iliac artery and corresponding vertebral body, increasing patient risk for deep vein thrombosis. Iliac vein stenting for patients with symptomatic May-Thurner syndrome has become standard practice in many centers. This article describes a patient whose stent embolized completely to the right ventricle, destroying most structures in its path.

Successful Percutaneous Endovascular Repair in a Very Large, Symptomatic, Non-ruptured Abdominal Aortic Aneurysm with Severe Neck Angulation.

Percutaneous endovascular aneurysm repair (PEVAR) is a minimally invasive treatment option for patients with abdominal aortic aneurysms (AAA). PEVAR allows for the lower incidence of vascular access site complications and decreased procedure time, yet the utility of this technique depends on the anatomical characteristics of the aneurysm. A detailed evaluation of the access site vessels and aneurysm neck anatomy are critical for standard patient and device selection. An 84-year-old male presented to our institution with the sudden onset of abdominal pain and confusion. Subsequent imaging demonstrated the presence of a 9.5 cm fusiform, infrarenal abdominal aortic aneurysm with a greater than 60-degree neck angulation and bilateral common iliac aneurysms. The patient underwent percutaneous endovascular aneurysm repair (PEVAR), and a type IB endoleak seen at the end of the case was treated successfully. At the one-year follow-up, the patient remained asymptomatic with the AAA stable in size.  This case represents the largest reported symptomatic unruptured AAA repaired with a completely percutaneous technique to date. Building up the stent-graft from the bifurcation with a unibody modular device may allow for support to address the severe angulation of a very hostile neck. PEVAR is a viable option in patients with symptomatic AAA and can be performed despite severe aneurysm neck angulation.

Management of gastric varices in the pediatric population with balloon-occluded retrograde transvenous obliteration (BRTO) utilizing sodium tetradecyl sulfate foam sclerosis with or without partial splenic artery embolization.

It is unknown whether spontaneous gastrorenal shunts actually develop in the pediatric population. The minimum age documented in studies from Asia is 32 (range 32-44) years. This study describes three pediatric patients undergoing balloon-occluded retrograde transvenous obliteration (BRTO) for bleeding gastric varices with two of the three patients undergoing combined partial splenic embolization. The first BRTO is a selective-BRTO via a surgical splenorenal shunt (15 years old) and the other two patients underwent conventional-BRTO via a spontaneous gastrorenal shunt (8 and 14 years old). The recurrent significant bleeding that they exhibited before the combined endovascular therapy did not recur for an average of 7.1 (range 1.4-14) months. In the second patient, quantitative digitally subtracted angiography was utilized to evaluate the inline portal venous flow before and after BRTO.

Risk-adjusted survival after coronary artery bypass grafting: implications for quality improvement.

Mortality represents an important outcome measure following coronary artery bypass grafting. Shorter survival times may reflect poor surgical quality and an increased number of costly postoperative complications. Quality control efforts aimed at increasing survival times may be misleading if not properly adjusted for case-mix severity. This paper demonstrates how to construct and cross-validate efficiency-outcome plots for a specified time (e.g., 6-month and 1-year survival) after coronary artery bypass grafting, accounting for baseline cardiovascular risk factors. The application of this approach to regional centers allows for the localization of risk stratification rather than applying overly broad and non-specific models to their patient populations.

Coil embolization of persistent false lumen after type A dissection repair.

A 44-year-old man with a type A dissection repair 5 years earlier presented with progressive enlargement of the residual arch and thoracic aorta. Flow into the false lumen from the distal aortic suture line was evident on contrast-enhanced computed tomography. Through a redo hemisternotomy, the false lumen was accessed directly. An Amplatzer plug was deployed within the narrowed neck of the false lumen proximal to the enlarged false lumen within descending aorta. Interlocking coils were deployed proximal to the Amplatzer plug, resulting in thrombosis of the false lumen.

Monoamine oxidase is a major determinant of redox balance in human atrial myocardium and is associated with postoperative atrial fibrillation.

BACKGROUND: Onset of postoperative atrial fibrillation (POAF) is a common and costly complication of heart surgery despite major improvements in surgical technique and quality of patient care. The etiology of POAF, and the ability of clinicians to identify and therapeutically target high-risk patients, remains elusive. METHODS AND RESULTS: Myocardial tissue dissected from right atrial appendage (RAA) was obtained from 244 patients undergoing cardiac surgery. Reactive oxygen species (ROS) generation from multiple sources was assessed in this tissue, along with total glutathione (GSHt) and its related enzymes GSH-peroxidase (GPx) and GSH-reductase (GR). Monoamine oxidase (MAO) and NADPH oxidase were observed to generate ROS at rates 10-fold greater than intact, coupled mitochondria. POAF risk was significantly associated with MAO activity (Quartile 1 [Q1]: adjusted relative risk [ARR]=1.0; Q2: ARR=1.8, 95% confidence interval [CI]=0.84 to 4.0; Q3: ARR=2.1, 95% CI=0.99 to 4.3; Q4: ARR=3.8, 95% CI=1.9 to 7.5; adjusted Ptrend=0.009). In contrast, myocardial GSHt was inversely associated with POAF (Quartile 1 [Q1]: adjusted relative risk [ARR]=1.0; Q2: ARR=0.93, 95% confidence interval [CI]=0.60 to 1.4; Q3: ARR=0.62, 95% CI=0.36 to 1.1; Q4: ARR=0.56, 95% CI=0.34 to 0.93; adjusted Ptrend=0.014). GPx also was significantly associated with POAF; however, a linear trend for risk was not observed across increasing levels of the enzyme. GR was not associated with POAF risk. CONCLUSIONS: Our results show that MAO is an important determinant of redox balance in human atrial myocardium, and that this enzyme, in addition to GSHt and GPx, is associated with an increased risk for POAF. Further investigation is needed to validate MAO as a predictive biomarker for POAF, and to explore this enzyme's potential role in arrhythmogenesis.

Race and survival among diabetic patients after coronary artery bypass grafting.

BACKGROUND: Diabetes is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined. METHODS: A retrospective cohort study was conducted for CABG patients between 1992 and 2011. Long-term survival was compared in patients with and without diabetes and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: Out of the 13,053 patients undergoing CABG, 35% (black n = 1,655; white n = 2,884) had diabetes at the time of surgery. The median follow-up for study participants was 8.2 years. Long-term survival after CABG was similar between black and white diabetic patients (no diabetes, HR = 1.0; white diabetic patients, adjusted HR = 1.5, 95%CI = 1.4-1.6; black diabetic patients, adjusted HR = 1.5, 95%CI = 1.4-1.7). CONCLUSION: A survival disadvantage after CABG was not observed among black versus white diabetic patients in our study.

The effect of preoperative ß-blocker use and race on long-term survival after coronary artery bypass grafting.

OBJECTIVE: To date, racial differences in the long-term survival of coronary artery bypass grafting (CABG) patients who receive preoperative ß-blockers have not been specifically examined. The purpose of this study was to examine the effect of preoperative ß-blockers on long-term survival among black CABG patients and to compare the magnitude of this effect with white patients. DESIGN: A retrospective cohort study. SETTING: A tertiary referral heart hospital. PARTICIPANTS: 13,354 patients undergoing CABG between 1992 and 2011. MEASUREMENTS AND MAIN RESULTS: Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 1,448 (62%) black and 6,094 (55%) white patients had a history of preoperative ß-blocker use. Among black patients, those receiving ß-blockers survived longer than those not receiving ß-blockers (adjusted HR = 0.77, 95% CI = 0.67-0.88). The survival advantage was comparable to that observed among white patients (adjusted HR = 0.88, 95% CI = 0.82-0.93). CONCLUSION: Black CABG patients benefited from preoperative ß-blockers and the magnitude of the effect was comparable to that among white patients.

The impact of race and postoperative atrial fibrillation on operative mortality after elective coronary artery bypass grafting.

OBJECTIVE: Black patients are less likely to develop postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) than whites. However, the influence of race and POAF on operative mortality has not been examined. The objective of this study was to determine the influence of race and POAF on operative mortality after CABG. METHODS: Patients undergoing elective CABG between 1992 and 2011 were included. Operative mortality was compared between patients with and those without new-onset POAF by race. Relative risk (RR) and 95% confidence intervals (CI) were computed using Poisson (robust variance estimates) and log-binomial regression models. RESULTS: A total of 1215 (23%) patients developed POAF (white n=1060; black n=155) following CABG (N=5387). Operative mortality differed by POAF status within race category (white POAF: adjusted RR=1.4, 95% CI=0.86-2.2; black POAF: adjusted RR=5.0, 95% CI=1.9-13; Pinteraction=0.0016). Black POAF patients had a 2-fold increased risk of operative death compared with white POAF patients (Padjusted=0.052). CONCLUSION: POAF was observed to be a stronger predictor of operative mortality in black compared with white patients undergoing elective CABG.

Propagating nanocavity-enhanced rapid crystallization of silicon thin films.

We demonstrate a mechanism of solid-phase crystallization (SPC) enabled by nanoscale cavities formed at the interface between an hydrogenated amorphous silicon film and embedded 30 to 40 nm Si nanocrystals. The nanocavities, 10 to 25 nm across, have the unique property of an internal surface that is part amorphous and part crystalline, enabling capillarity-driven diffusion from the amorphous to the crystalline domain. The nanocavities propagate rapidly through the amorphous phase, up to five times faster than the SPC growth rate, while "pulling behind" a crystalline tail. Using transmission electron microscopy it is shown that twin boundaries exposed on the crystalline surface accelerate crystal growth and influence the direction of nanocavity propagation.

Racial differences in survival among hemodialysis patients after coronary artery bypass grafting.

The aim of this study was to examine racial differences in long-term survival among hemodialysis patients after coronary artery bypass grafting (CABG). To our knowledge this has not been previously addressed in the literature. Black and white hemodialysis patients undergoing first-time, isolated CABG procedures between 1992 and 2011 were compared. Survival probabilities were computed using the Kaplan-Meier product-limit method and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 207 (2%) patients were on hemodialysis at the time of CABG. White (n = 80) hemodialysis patients had significantly decreased 5-year survival compared with black (n = 127) patients (adjusted HR = 1.9, 95% CI = 1.2-2.8). Our finding provides useful outcome information for surgeons, primary care providers, and their patients.

The effect of race and chronic obstructive pulmonary disease on long-term survival after coronary artery bypass grafting.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined. METHODS: A retrospective cohort study was conducted of CABG patients between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 984 (20%) patients had COPD (black n = 182; white n = 802) at the time of CABG (N = 4,801).The median follow-up for study participants was 4.4 years. COPD was observed to be a statistically significant predictor of decreased survival independent of race following CABG (no COPD: HR = 1.0; white COPD: adjusted HR = 1.9, 95% CI = 1.7-2.3; black COPD: adjusted HR = 1.6, 95% CI = 1.1-2.2). CONCLUSION: Contrary to the expected increased risk of mortality among black COPD patients in the general population, a similar survival disadvantage was not observed in our CABG population.

Impact of race and postoperative atrial fibrillation on long-term survival after coronary artery bypass grafting.

BACKGROUND AND AIM: Postoperative atrial fibrillation (POAF) is a known predictor of in-hospital morbidity and short-term survival after coronary artery bypass grafting (CABG). The impact of race and long-term survival has not been examined in this population. We aimed to examine the influence of these factors on long-term survival in patients undergoing CABG. METHODS: Patients undergoing first-time, isolated CABG between 1992 and 2011 were included in this study. Long-term survival was compared in patients with and without POAF and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 2,907 (22%) patients developed POAF (black n=370; white n=2,537) following CABG (N=13,165). Median follow-up for study participants was 8.2 years. Long-term survival after CABG differed by POAF status and race (no POAF: HR=1.0; white POAF: adjusted HR=1.1, 95% CI=1.06-1.2; black POAF: adjusted HR=1.4, 95% CI=1.2-1.6; pTrend=0.0002). lack POAF patients also died sooner after surgery than their white counterparts (adjusted HR=1.2, 95% CI=1.02-1.4). CONCLUSION: Black race was a statistically significant predictor of decreased survival among POAF patients after CABG. This finding provides useful outcome information for surgeons and their patients.

Preoperative atrial fibrillation and long-term survival after open heart surgery in a rural tertiary heart institute.

BACKGROUND: Preoperative atrial fibrillation (AF) is associated with increased morbidity and mortality after open heart surgery. However, the impact of preoperative AF on long-term survival after open heart surgery has not been widely examined in rural populations. Patients from rural regions are less likely to receive treatment for cardiac conditions and to have adequate medical insurance coverage. OBJECTIVE: To examine the influence of preoperative AF on long-term survival following open heart surgery in rural eastern North Carolina. METHODS: Long-term survival was compared in patients with and without preoperative AF after coronary artery bypass grafting (CABG) and CABG plus valve (CABG + V) surgery between 2002 and 2011. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: The study population consisted of 5438 patients. A total of 263 (5%) patients had preoperative AF. Preoperative AF was an independent predictor of long-term survival (open heart surgery: adjusted HR = 1.6, 95% CI = 1.3-2.0; CABG: adjusted HR = 1.6, 95% CI = 1.3-2.1; CABG + V: adjusted HR = 1.6, 95% CI = 1.1-2.3). CONCLUSION: Preoperative AF is an important predictor of long-term survival after open heart surgery in this rural population.

The impact of prior percutaneous coronary intervention on long-term survival after coronary artery bypass grafting.

BACKGROUND: Previous studies examining the influence of prior percutaneous coronary intervention (PCI) on long-term survival after coronary artery bypass grafting (CABG) have reported conflicting results. The purpose of this study was to further examine the influence of prior PCI on long-term survival after CABG at a large tertiary referral heart institute. METHODS: Long-term survival between 1992 and 2011 was compared in non-emergent CABG cases with and without prior PCI. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 2532 (19%) patients had prior PCI before CABG (n=13,354). The median follow-up for study participants was 8.1 years. The median survival for patients with and without prior PCI was 15 years and 14 years, respectively (p<0.0001). Long-term survival was similar between patients with and without prior PCI after adjusting for age, sex, race, hypertension, coronary artery disease severity, congestive heart failure, and prior stroke (adjusted HR=0.99, 95%CI=0.91-1.06). CONCLUSION: Findings from outcomes research are important in the planning of appropriate postoperative patient care. Our study provides additional evidence that prior PCI is not a significant predictor of long-term survival after CABG.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients: technical analysis and clinical outcome.

OBJECTIVE: The purpose of this study is to compare the technical success of transjugular intrahepatic portosystemic shunt (TIPS) in transplanted versus nontransplanted livers and to assess the clinical outcome of TIPS in liver transplant recipients. MATERIALS AND METHODS: A retrospective audit of patients receiving a TIPS was performed in two institutions during 1996-2009. The technical success of the TIPS was compared for transplanted versus nontransplanted livers. Clinical success was defined as graft survival longer than 1 month with improvement in symptoms. The cohort was divided into grafts that survived less than 3 months versus 3 months or more. The model for end-stage liver disease (MELD) scores and portosystemic gradients before and after TIPS creation were evaluated for predictive value for graft survival. The TIPS stent type, MELD scores and portosystemic gradients before and after TIPS creation, and causes of liver disease were evaluated for their predictive value for ascites response after TIPS creation. RESULTS: Thirty-nine TIPS in transplanted livers were found, representing 5.5% (39/715) of all TIPS procedures performed and 2.0% (39/1992) of all liver transplant recipients. Ninety percent of TIPS in transplanted livers had ascites. The median time from transplant to creation of the TIPS was 29 months (2-127 months). The median MELD score was 16 before and 22 after the TIPS procedure. The technical success rates for TIPS were 97% (38/39) in transplanted livers versus 97% (657/676) in nontransplanted livers (p = 1.00). Intent-to-treat clinical success rates were 36% for all indications versus 31% for ascites only. There were no predictors for ascites response. Six-, 12-, and 24-month graft survival rates were 43%, 32%, and 22%, respectively. One-year graft survival for a MELD score less than 17 versus a score of 17 or higher was 54% versus 8%, respectively (p < 0.05). CONCLUSION: Transplantation does not pose a technical challenge to TIPS creation. One third of patients have a favorable outcome. MELD score is the only predictor of graft survival.

Implications of Hemodialysis in Patients Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality in patients on hemodialysis. To our knowledge, no studies have examined long-term outcomes of hemodialysis patients following coronary artery bypass grafting (CABG) in a predominately rural, low-income, and racially dichotomous population. METHODS: Long-term survival of hemodialysis patients undergoing non-emergent, isolated CABG was compared with non-hemodialysis patients. Survival probabilities were computed using the Kaplan-Meier product limit method and stratified by hemodialysis. Hazard ratios (HR) and 95% confidence intervals (95%CI) were computed using a Cox regression model. RESULTS: Hemodialysis patients (n=220) had shorter long-term survival than non-hemodialysis patients (median survival=3.3 versus 14 years, p<0.0001). The survival difference remained statistically significant after adjusting for clinically relevant variables (HR=5.2, 95%CI=4.4-6.2). CONCLUSION: Hemodialysis patients had significantly shorter long-term survival compared with non-hemodialysis patients after CABG. Further research is needed to address the cost and policy implications of our findings, especially among priority populations.

Delayed left ventricle-to-right atrial fistula following aortic valve replacement.

Fistula development between the left ventricular outflow tract and right atrium is a rare complication of aortic valve replacement (AVR), typically seen with calcific aortic stenosis or endocarditis. The case is reported of a left ventricle-to-right atrial fistula following mechanical AVR for aortic insufficiency.

An acute animal model of aortic stenosis: initial attempts at leaflet modification.

BACKGROUND AND AIM OF THE STUDY: Percutaneous valve insertion is an emerging treatment for aortic stenosis (AS). To date, no large animal model exists that replicates human calcific AS; moreover, the absence of any valve pathology in currently available animal models prevents their use in any realistic assessment of percutaneous aortic valve therapy. Hence, the aim of the present study was to create an acute large animal model in which human calcific AS could be simulated. METHODS: Ten domestic swine underwent open-heart surgery utilizing cardiopulmonary bypass (CPB) and cardioplegic arrest. The aortic valve annulus and leaflets were injected with cyanoacrylate, after which epicardial echocardiography was used to assess the creation of AS. At the time of animal sacrifice, the hearts were harvested for gross and histopathological examination. RESULTS: The leaflet and annular injections were performed successfully in all animals. Subsequently, seven animals were weaned from CPB and underwent post procedural echocardiographic evaluations, whereby the treated valves were harvested for gross and histological examination. CONCLUSION: Cyanoacrylate can be injected into the porcine aortic valve and annulus to create a model that resembles human calcific AS in the acute setting. Additional long-term follow up studies must be conducted, however, before this model can be utilized in the development of percutaneous valve therapy.