Dissection Re-entry Technique: How is it Really Looking?

Dissection re-entry is a widely used technique in many chronic total occlusion centers. This account of a failed re-entry attempt provides in vivo photographic evidence of how the vessel looked after such an attempt. Operators are advised to keep dissection of subintimal space and hematoma limited and use dedicated materials and techniques for controlled re-entry.

Aorta no-touch off-pump coronary artery revascularization in octogenarians: 5 years' experience.

BACKGROUND: Approximately 18% of octogenarians have ischemic heart disease. Increasingly, they are being referred for coronary artery revascularization by surgical and/or percutaneous procedures. These strategies have been questioned, however, because of reports of poor outcomes in the elderly. In this study, we aimed to determine the impact of age on morbidity and mortality in patients undergoing off-pump coronary artery bypass (OPCAB) with the pi-circuit procedure during 5 years of follow-up. MATERIALS AND METHODS: From February 2001 to November 2005, 1359 patients underwent isolated coronary revascularization with the pi-circuit technique, which consists of (1) beating heart surgery, (2) OPCAB, (3) no touching of the aorta, (4) use of composite grafts, and (5) arterial revascularization. Sixty-two patients were > or = 80 years of age (group A), and 1297 were <80 years old (group B). Both groups were compared with respect to preoperative risk factors, intraoperative parameters, and postoperative morbidity and mortality. Follow-up lasted from 4 to 60 months. Data were analyzed with the chi(2) test, the Fisher exact test, the Kaplan-Meier method, and the Cox model of regression analysis. RESULTS: Females predominated among the octogenarians (P < .0005). Octogenarians more frequently underwent emergent operations (P < .031) and had worse ejection fractions (P < .026). Obesity was also less prevalent among these patients (P < .007). There were no differences between the groups in the preoperative and postoperative use of an intraaortic balloon pump. Octogenarians had lower cholesterol levels (P < .0005) and had fewer distal anastomoses (2.24 + or - 0.0.76 versus 2.77 + or - 0.92, P < .0005). The 2 groups were not significantly different with respect to 30-day mortality (3.2% versus 1.5%) and 7-day mortality (1.6% versus 0.2%). Differences were noted in the incidences of pulmonary complications (12.9% versus 5.6%, P < .027), atrial fibrillation (41.9% versus 19%, P < .0005), and cognitive disturbances (6.5% versus 0.3%, P < .0005). During follow-up, survival seemed to favor the younger group (P < .001). Nevertheless, further analysis of the data with the Cox regression model to exclude confounding risk factors, revealed the survival rates of the 2 groups to be similar. CONCLUSIONS: Use of the pi-circuit technique is very effective for octogenarians. Although these older patients have a higher incidence of early postoperative morbidity, overall survival is not affected.

Effective combined off-pump surgical treatment and autologous bone marrow cell transplantation: a new alternative for patients with end-stage ischemic cardiomyopathy (Prapas' procedure).

OBJECTIVE: To propose an alternative method combined off-pump treatment of end-stage ischemic cardiomyopathy consisting of revascularization of ischemic areas, external reshaping of the left ventricle (LV) in order to restore near normal geometry and autologous bone marrow-derived mononuclear cell (BM-MNC) implantation. METHODS: Forty- seven patients (mean age 58+/-8.9 years) underwent the above procedure. All patients were NYHA III-IV and four were transplantation candidates. They underwent standard laboratory evaluation, transthoracic echocardiography, dipyridamole thallium scintigraphy (DTS) and cardiac magnetic resonance imaging preoperatively and at 3rd, 6th and 12th months postoperatively. After revascularization and external LV reshaping, BM-MNCs were injected into predetermined peri-infarct areas. RESULTS: Forty-five patients survived during a follow up period of 3-37 months. Ejection fraction improved from 21.7+/-7.4% to 30.6+/-6.9%, 36.5+/-4.3% and 37.7+/-4.2% at 3rd, 6th and 12th months, respectively. Left ventricular end-diastolic diameter was reduced from 66.1+/-4.9 mm to 62.6+/-3.9 mm, 60.5+/-2.9 mm and 59.3+/-4.2 mm respectively. Previously non-viable areas on DTS were found to contain viable tissue and MRI showed hypokinesia in previously akinetic areas. NYHA class improved to I-II. No significant arrhythmias were noted during the follow-up period. One patient died due to low cardiac output and one patient died due to septic shock. CONCLUSIONS: Combined off-pump surgical treatment and autologous bone-marrow mononuclear cell transplantation for end-stage ischemic cardiomyopathy is safe and feasible and appears to improve the patients' functional status.

Predictors of prolonged mechanical ventilation following aorta no-touch off-pump coronary artery bypass surgery.

OBJECTIVE: To identify parameters associated with prolonged mechanical ventilation (PMV) (>48 h) after off-pump coronary artery bypass (OPCAB) in our patient population. MATERIALS AND METHODS: From February 2001 to November 2005, we operated on 1359 patients for isolated coronary revascularization with the pi-circuit technique, consisting of: (1) beating heart, (2) OPCAB, (3) aorta no-touch, (4) use of composite grafts, and (5) arterial revascularization. RESULTS: From the total number of our patients, 1320 patients had been extubated within 48 h postoperatively (Group A) and 39 patients needed PMV (Group B). In our study we have found that PMV were associated with advanced age (64.74+/-9.85 Group A vs 68.43+/-10.03 Group B, p<0.02) as well as higher incidence with octogenarians (4.4% Group A vs 10.2% Group B, p=0.09). Patients with preoperative history of transient ischemic attacks (TIAs) or stroke were more likely to belong to Group B (1.5% Group A vs 7.7% Group B, p<0.02; 2.8% Group A vs 10.3% Group B, p<0.02, respectively). Preoperative intra-aortic balloon pump (IABP) insertion was associated with PMV (1.6% Group A vs 15.4% Group B, p<0.0005). Unexpectedly, neither COPD nor obesity was associated with PMV (4.9% Group A vs 7.7% Group B, p=NS, 21.7% Group A vs 23.1% Group B, p=NS, respectively). CONCLUSION: In this study, PMV following aorta no-touch OPCAB was related to preoperative variables: age, octogenarians, preoperative IABP, TIA, and stroke. There was no relation between PMV and any of the operative data.

Predictors of early postoperative atrial fibrillation after off-pump myocardial revascularization.

OBJECTIVE: : We determined the incidence and the predisposing factors of atrial fibrillation (AF) after aorta nontouch coronary artery bypass grafting without extracorporeal circulation. METHODS: : From February 2001 to November 2005, 1359 patients (1159 men, 85.3%) of mean (±SD) age 64.8 (±9.8) years, who underwent off-pump coronary artery bypass grafting (OP-CAB), were prospectively enrolled. Demographics, perioperative data, and comorbidities were recorded in all patients. A 24-hour rhythm monitoring was performed in all patients until hospital discharge. RESULTS: : Among 1359 patients, 273 (20.1%) had development of atrial fibrillation in the early postoperative period. Patients with AF had higher mean (±SD) age, 68.3 (±8.8) years, compared with control subjects [63.9 (±9.9)] (P ≤ 0.0005). Univariate analysis showed that apart from age, history of arterial hypertension (P ≤ 0.02), chronic obstructive pulmonary disease (P ≤ 0.02), and the use of bilateral internal mammary arteries (P ≤ 0.01) were predisposing factors for the development of AF. Logistic regression analysis showed that age, history of arterial hypertension, and the use of bilateral internal mammary arteries were predisposing factors for early postoperative AF after OP-CAB. CONCLUSIONS: : Atrial fibrillation occurred in approximately 20% of patients undergoing OP-CAB, mainly in older patients with arterial hypertension who received bilateral internal mammary artery grafts.