Invasive Giant B-Cell Lymphoma Mimicking Fulminant Pulmonary Embolism.

Background Cardiac non-Hodgkin's lymphoma is rare and has a poor prognosis. Here we report a rare case mimicking pulmonary embolism. Case Description A 38-year-old woman suffered from severe dyspnea after cesarean section. With the clinical picture of fulminant central pulmonary embolism, lysis therapy was initiated. Further deterioration necessitated extracorporeal membrane oxygenation (ECMO) support and cardiosurgical intervention. Intraoperatively, a massive intravascular tumor obstructed the pulmonary bifurcation and was found to be B-cell lymphoma. Aggressive excision and pulmonary tree reconstruction improved the critical condition and initiated convalescence. Conclusion High suspicion in central pulmonary embolism and early cardiosurgical therapy after ineffective lysis are essential.

ST-Segment Elevation Myocardial Infarction and Right Atrial Myxoma.

Background Cardiac myxoma is the most common primary cardiac tumor. Although benign, it can cause life-threatening complications due to embolization. Case Presentation We describe an ST-elevation myocardial infarction (STEMI) involving a giant right atrial myxoma and persisting foramen ovale (PFO) in a 64-year-old male patient and report on emergency percutaneous interventional therapy and subsequent cardiac surgery to remove the right atrial myxoma. Conclusion A right atrial myxoma, combined with a PFO, can cause a STEMI. Therefore, every acute coronary syndrome patient should undergo ultrafast exploratory emergency echocardiography to protect the physician from unpleasant surprises.

Is implantable cardioverter defibrillator surgery in patients with an implanted left ventricular assist device safe under uninterrupted oral anticoagulation?

BACKGROUND: Implantable cardioverter-defibrillator (ICD) surgery in patients with implanted left ventricular assist devices (LVAD) is associated with an increased risk of bleeding complications because of the need to ensure that these patients are adequately anticoagulated. Our study aimed to evaluate the safety of our new strategy of uninterrupted oral anticoagulation compared to heparin-bridging during the surgical interval. METHODS: Between January 2009 and January 2020, 116 patients with LVAD underwent ICD surgery. Since January 2015, 60 patients were operated under continued sufficient oral anticoagulation with a vitamin k antagonist (VKA group). Fifty-six patients underwent a heparin-bridging regimen (heparin group). Demographics, perioperative data, complications, and mortality were analyzed. RESULTS: Bleeding complications attributable to the surgical intervention occurred more often (19.6% vs. 10.0%, p = 0.142) and at a higher rate of re-exploratory surgery (14.3% vs. 5.0%, p = 0.088) in the heparin group without reaching statistical significance. Moreover, the heparin group patients' postoperative total length of stay was 10 days longer (17.8 ± 23.8 days vs. 8.3 ± 9.5 days, p = 0.007). There were no procedure-related deaths, no thromboembolic events, and no LVAD-related thrombosis. CONCLUSION: Our strategy of uninterrupted oral anticoagulation is safe and results in a reduction by more than half the number of days in hospital without an increase in adverse events.

Giant Intramural Right Ventricular Hematoma after PCI in a Patient with Condition after CABG.

Coronary artery perforation secondary to percutaneous coronary intervention (PCI) is a rare, but a potentially life-threatening complication. There is a misconception that cardiac tamponade rarely occurs in patients with prior coronary artery bypass grafting (CABG). We first describe a giant right ventricular intramural hematoma following PCI via a saphenous vein graft to treat a distal stenosis of the right coronary artery, and its successful treatment with redo cardiac surgery. Complex elective PCIs on patients after CABG should be performed in specialized centers with a well-established heart team that has the expertise to treat any of the potential complications.

Evaluation of Strategies in the Management of Infective Aortic Valve Endocarditis at German Cardiac Surgical Departments.

BACKGROUND: Surgical treatment of infective aortic valve endocarditis (AVE) remains a therapeutic challenge, necessitating interdisciplinary approach to limit morbidity and mortality in this high-risk cohort. With a considerable spectrum of available laboratory testings, imaging techniques, as well as operative strategies developed in recent years, there is a lack of standardization across cardiac surgical departments in Germany. Thus, the optimal treatment strategy of AVE has yet to be defined. METHODS: A nationwide survey on infective AVE was conducted, including 64 cardiac surgical departments responding to a 41-item questionnaire. The evaluation included common surgical practice, routine diagnostic steps, surgical techniques, perioperative medical treatment, as well as postoperative management. RESULTS: Remarkable differences were observed among the participating institutions, including the following components of the treatment: (1) standardization and extent of the use of imaging techniques and (2) success rate in identification AVE-causing germs, (3) timing of operation in case of cerebral embolization, and (4) choice of valve prosthesis for aortic valve replacement for infective AVE. CONCLUSION: The findings of this survey underline the need for a nationwide registry to further elucidate the nature and course of AVE in Germany, as well as to serve as a solid basis for prospective trials, addressing the most important clinical purposes in the diagnosis and treatment of AVE.

Evaluation of risk factors for a fulminant Clostridium difficile infection after cardiac surgery: a single-center, retrospective cohort study.

BACKGROUND: Clostridium difficile (CD) is the most common pathogen causing nosocomial diarrhea. The clinical presentation ranges from mild diarrhea to severe complications, including pseudomembranous colitis, toxic megacolon, sepsis, and multi-organ failure. When the disease takes a fulminant course, death ensues rapidly in severe and complex cases. Preventive screening or current prophylactic therapies are not useful. Therefore, this study was conducted to detect risk factors for a fulminant CD infection (CDI) in patients undergoing cardiac surgery. METHODS: Between April 1999 and April 2011, a total of 41,466 patients underwent cardiac surgery at our institution. A review of our hospital database revealed 1256 patients (3.0%) with post-operative diarrheal disease who tested positive for CD; these patients comprised the cohort of this observational study. A fulminant CDI occurred in 153 of these patients (12.2%), which was diagnosed on the basis of gastrointestinal complications, e.g. pseudomembranous colitis, and/or the need for post-cardiac surgery laparotomy. Demographic, peri-operative, and survival data were analyzed, and predictors of a fulminant CDI were assessed by binary logistic regression analysis. RESULTS: The 30-day mortality was 6.1% (n = 77) for the entire cohort, with significantly higher mortality among patients with a fulminant CDI (21.6% vs. 4.0%, p <  0.001). Overall mortality (27.7%, n = 348) was also higher for patients with a fulminant course of the disease (63.4% vs. 22.8%, p <  0.001), and a laparotomy was required in 36.6% (n = 56) of the fulminant cases. Independent predictors of a fulminant CDI were: diabetes mellitus type 2 (OR 1.74, CI 1.15-2.63, p = 0.008), pre-operative ventilation (OR 3.52, CI 1.32-9.35, p = 0.012), utilization of more than 8 units of red blood cell concentrates (OR 1.95, CI 1.01-3.76, p = 0.046) or of more than 5 fresh-frozen plasma units (OR 3.38, CI 2.06-5.54, p <  0.001), and a cross-clamp time > 130 min (OR 1.93, CI 1.12-3.33, p = 0.017). CONCLUSIONS: We identified several independent risk factors for the development of a fulminant CDI after cardiac surgery. Close monitoring of high-risk patients is important in order to establish an early onset of therapy and thus to prevent a CDI from developing a fulminant course after cardiac surgery.

Impact of sleep disordered breathing on short-term post-operative outcome after elective coronary artery bypass graft surgery: a prospective observational study.

Sleep disordered breathing (SDB) is common in patients with coronary disease, but its impact on post-operative recovery after coronary artery bypass graft surgery (CABG) is unclear. We therefore determined the effects of SDB on post-operative outcome after elective CABG.In this prospective two-centre study, 219 patients due to receive elective CABG underwent cardiorespiratory polygraphy for SDB prior to surgery and were monitored for post-operative complications. The primary end-point was a composite of 30-day mortality or major post-operative complications (cardiac, respiratory, surgical, infectious, acute renal failure or stroke). Key secondary end-points were single components of the primary end-point.SDB was present in 69% and moderate/severe SDB in 43% of the CABG patients. There was no difference in the composite of 30-day mortality or major postoperative complications between patients with and without SDB (OR 0.97, 95% CI 0.49-1.96) and between patients with moderate/severe SDB and no/mild SDB (OR 1.07, 95% CI 0.55-2.06). However, moderate/severe SDB was associated with higher rates of mortality (crude OR 10.1, 95% CI 1.22-83.5), sepsis (OR 2.96, 95% CI 1.17-7.50) and respiratory complications (OR 2.85, 95% CI 1.46-5.55).Although SDB was not associated with higher overall morbidity/mortality, moderate/severe SDB may increase the risk of death, and septic and respiratory complications, after elective CABG.

The reverse remodeling effect of mesenchymal stem cells is independent from the site of epimyocardial cell transplantation.

OBJECTIVE: The transplantation of mesenchymal stem cells (MSCs) represents a promising approach for treating the ischemic and the nonischemic diseased heart. The positive effects of transplanting these cells could be shown, but the exact mechanisms remain unknown. We evaluated whether the injection site affects the improvement in left ventricular (LV) ejection fraction (EF) and angiogenesis in doxorubicin (Dox)-induced failing hearts. METHODS: Heart failure was induced in New Zealand white rabbits by doxorubicin treatment, followed by right ventricular MSC transplantation (RV-MSC, n = 6), LV MSC transplantation (LV-MSC, n = 6), sham treatment (sham group, n = 6), or no therapy (Dox group, n = 5). Healthy rabbits were used as control group (n = 8). Cells were isolated after bone marrow aspiration and transplanted locally into the ventricular myocardium. After 4 weeks, cardiac function and capillary density (CD31 staining) were measured. RESULTS: The transplantation of MSCs increased the EF significantly (LV-MSC, 39.0% ± 1.4%, and RV-MSC, 39.2% ± 2.6%, vs sham group, 29.8% ± 3.7%; P < 0.001), without significance between the MSC groups (P = 0.858). Neither the evidence of a transdifferentiation nor any signs of cell engraftment of transplanted cells could be found. The capillary density (capillaries/high-power field) increased in both MSC groups compared with the sham group (LV-MSC by 8.3% ± 3.4%; and RV-MSC, 8.1% ± 2.2%; P < 0.05), without significance between the two MSC groups (P = 0.927). CONCLUSIONS: Injection of autologous MSCs in doxorubicin-induced cardiomyopathic rabbit hearts improves EF and enhances angiogenesis. Despite local application, we observed global effects on heart function and capillary density without significant difference between right and LV injection. The paracrine mechanism might be one possible explanation for these findings.

Pharmacokinetics of intraluminally administered serum papaverine for spasm prophylaxis of the internal mammary artery.

BACKGROUND: Papaverine (Paveron N™ Linden Arzneimittel Vertrieb GmbH, Germany) is a widely used agent for preventing spasm in mammary artery preparations. The question addressed in this study is whether the intraluminal administration of papaverine can result in detectable absorption of the drug into the systemic arterial circulation. METHODS: In 15 patients (age 65 ± 6 years; body mass index 28.9 ± 3.7), an internal mammary artery (IMA) was prepared during coronary artery bypass grafting (CABG). A maximum of 3 mL of a 1 mg/1 mL diluted papaverine solution was injected intravascularly (intraluminally) for spasm prophylaxis. The IMA was closed proximally and distally with bulldog clamps. Blood samples were taken immediately after administration (T1), after 20 minutes (T2), and at the end of the operation (T3). Samples were measured in a liquid chromatography-tandem mass spectrometry (LC-MS/MS) system consisting of a binary pump from Agilent (Waldbronn, Germany) coupled to a high-throughput screening (HTS) PAL injection system (CTC, Zwingen, Switzerland) and a tandem mass spectrometer (API 4000, AB Sciex, Darmstadt, Germany). Papaverine was analyzed in positive mode using an electrospray ion source. Quantitation was performed using Analyst 1.5 software (AB Sciex, Darmstadt, Germany). RESULTS: The newly developed LC-MS/MS method was successfully established for the detection of papaverine in plasma samples. The highest plasma papaverine levels were determined at time point T1 (mean 54.7 ± 39 ng/mL, range 16.6-179 ng/mL). The concentration was already halved 20 minutes after administration (T2) (mean 23.3 ± 2 ng/mL, range 4.6-118 ng/mL). Because of the short half-life and the hemodilution in the extracorporeal circulation, at the end of the operation papaverine (T3) had already fallen to just above the limit of detection (mean 4.1 ± 3.9 ng/mL, range 1.3-16.9 ng/mL). At time point T1, a significant negative correlation was determined between plasma levels and systemic diastolic, but not systolic, blood pressure. CONCLUSION: Papaverine was successfully determined systemically in plasma by LC-MS/MS after intraluminal administration in the IMA. Systemic circulatory effects are dependent on the detected quantity. Group size and the absence of a control group are considerable limitations.

Is the new EuroSCORE II a better predictor for transapical aortic valve implantation?

OBJECTIVES: Conventional surgical risk scores are used to identify suitable candidates for transapical aortic valve implantation (TA-AVI) at present. However, these scores do not consider multiple high-risk conditions, including porcelain aorta, mediastinal irradiation or frailty. The aim of this study was to compare the predictive ability of the new EuroSCORE II with the surgical risk scores currently in use. METHODS: From February 2006 to May 2011, 360 consecutive high-risk patients, age 81.6 ± 6.4 years, 64.4% female, were included using the Edwards SAPIEN™ prosthesis. The prognostic value of the EuroSCORE II was evaluated and compared with the logistic EuroSCORE and STS mortality score by receiver operating characteristics (ROC) curve analysis. In addition, a Spearman correlation analysis was performed, and a stepwise multivariate Cox regression used to identify the independent risk factors of mortality. RESULTS: The STS score and EuroSCORE II (r = 0.504, P < 0.001) showed a good correlation, while a strong correlation was found between the logistic EuroSCORE and EuroSCORE II (r = 0.717, P < 0.001). Thirty-day and in-hospital mortality rates were 10.6% (38 of 360) and 11.4% (41 of 360), respectively. In-hospital mortality rate was estimated by the logistic EuroSCORE: 30.0 ± 15.7%, the STS score: 11.7 ± 7.8% and the EuroSCORE II: 6.7 ± 5.1%. The prognostic values of the STS score, logistic EuroSCORE and the recent EuroSCORE II systems were analysed by ROC curve analysis for the prediction of 30-day (area under the curve, AUC: 0.64 vs 0.55 vs 0.50) and in-hospital mortality (AUC: 0.65 vs 0.54 vs 0.49). Multivariate regression analysis revealed length of preoperative hospital stay >5 days, body weight <65 kg, preoperative aortic annular diameter ≤ 20 mm, vital capacity <70% and concomitant mitral regurgitation >1+ as independent risk factors. CONCLUSION: In patients undergoing TA-AVI, the new EuroSCORE II correlates strongly with the logistic EuroSCORE, but is a poorer predictor of 30-day and in-hospital mortality than the STS score. A true transcatheter aortic valve implantation risk score would be desirable beyond the established scores.

Surgical therapy of atrial fibrillation.

Atrial fibrillation (AF) can be found in an increasing number of cardiac surgical patients due to a higher patient's age and comorbidities. Atrial fibrillation is known, however, to be a risk factor for a greater mortality, and one aim of intraoperative AF treatment is to approximate early and long-term survival of AF patients to survival of patients with preoperative sinus rhythm. Today, surgeons are more and more able to perform less complex, that is, minimally invasive cardiac surgical procedures. The evolution of alternative ablation technologies using different energy sources has revolutionized the surgical therapy of atrial fibrillation and allows adding the ablation therapy without adding significant risk. Thus, the surgical treatment of atrial fibrillation in combination with the cardiac surgery procedure allows to improve the postoperative long-term survival and to reduce permanent anticoagulation in these patients. This paper focuses on the variety of incisions, lesion sets, and surgical techniques, as well as energy modalities and results of AF ablation and also summarizes future trends and current devices in use.

Aortic valve calcium scoring is a predictor of significant paravalvular aortic insufficiency in transapical-aortic valve implantation.

OBJECTIVE: Transapical-aortic valve implantation (TA-AVI) has evolved as routine for selected high-risk patients. However, paravalvular leaks >1+ remain an unsolved issue using current generations of transcatheter valve devices. The purpose of this study was to investigate the impact of native aortic valve calcification on paravalvular leaks and outcomes using the Edwards SAPIEN™ prosthesis. METHODS: One hundred and twenty consecutive patients (out of 307 TA-AVIs) with preoperative computed tomography aged 82.6 ± 6.2 years, 75.0% female were included. Implanted prosthetic valve sizes were 23 mm (n = 31) and 26 mm (n = 89), respectively. Mean logistic European System for Cardiac Operative Risk Evaluation-Score was 30.1 ± 15.5% and mean Society of Thoracic Surgeons-Score was 12.8 ± 7.9%. Electrocardiographic (ECG)-gated cardiac computed tomography allowed to quantify the amount of calcification of aortic valve leaflets using a scoring analogous to the Agatston calcium scoring of coronary arteries [Aortic Valve Calcium Scoring (AVCS)]. Paravalvular leaks were assessed intraoperatively by echocardiography and root angiography. RESULTS: All valves were implanted successfully. The mean AVCS in patients without paravalvular leaks (n = 66) was 2704 ± 1510; with mild paravalvular leaks (n = 31) was 3804 ± 2739 (P = 0.05); and with moderate paravalvular leaks (n = 4) was 7387 ± 1044 (P = 0.002). There was a significant association between the AVCS and paravalvular leaks [odds ratio (OR; per AVCS of 1000), 11.38; 95% confidence interval (CI) 2.33-55.53; P = 0.001)] and a trend towards a higher incidence of new pacemaker implantation (OR 1.27; 95% CI 0.85-1.89; P = 0.26). No association was found to 30-day mortality, major cardiac events and stroke rate (OR 1.05; 95% CI 0.84-1.32; P = 0.68; OR 0.92; 95% CI 0.68-1.25; P = 0.57 and OR 0.90; 95% CI 0.41-1.96; P = 0.79, respectively). Overall 30-day mortality was 14.2%. CONCLUSION: Severe native valve calcifications are predictive for postoperative relevant paravalvular leak. AVCS prior to TA-AVI might serve as an additional tool to reconsider the TAVI indication to reduce the risk of paravalvular leaks especially in so-called operable patients.

Bioresorbable adhesion barrier for reducing the severity of postoperative cardiac adhesions: Focus on REPEL-CV(®).

Treatment of a number of congenital heart defects often necessitates staged surgical intervention. In addition, substantial improvements in postoperative cardiac care and more liberal use of biological valve substitutes have resulted in many adult patients surviving to become potential candidates for reoperations to repair or replace valves or to undergo additional revascularization procedures. In all these scenarios, surgeons are confronted with cardiac adhesions, leading to an increased surgical risk. Thus, bioresorbable adhesion barriers had become of increasing interest because they are easy to use, and safe and effective. This review focuses on the mechanisms by which REPEL-CV(®) prevents adhesive processes, as well as the development, design, and materials used, and also summarizes efficacy studies, clinical data, safety, and current role in therapy.

Visceral arterial compromise during intra-aortic balloon counterpulsation therapy.

BACKGROUND: Intraaortic balloon pump (IABP) therapy is a widely used method of circulatory support. Based on frequent findings of balloon malposition with visceral arterial compromise on computerized tomographic (CT) imaging studies, we conducted a systematic review of cardiac surgical IABP patients with available CT scans to determine reasons, incidence, and clinical relevance of malposition. METHODS AND RESULTS: From January 2007 to March 2009, a total of 621 of 7756 cardiac surgical patients (8.0%) received perioperative IABP support, of whom 63 (10.1%) received a thoracoabdominal CT scan during IABP support. Proximal and distal balloon positions were analyzed. The anatomic distance from the left subclavian artery to celiac trunk and aortic transverse diameter were measured in all patients and compared with implanted balloon dimensions. Mean age was 67.1±11.9 years; 33.3% were female, and height was 169±9 cm. Based on radiography, proximal balloon position was correct in 96.8% but only appropriate in 38.1% based on CT. In 61 of 63 patients, compromise of at least 1 visceral artery was found: celiac trunk, 96.8%; superior mesenteric artery, 87.3%; and renal arteries, 66.7%. Left subclavian artery to celiac trunk distance was 241±23 mm, and balloon length was 248±17 mm and corresponded to an anatomic to balloon length mismatch in 68.2%. Spinal deformations were found in 42.9%. Laparotomy for mesenteric ischemia was required in 23.8%. Hospital mortality rate was 60.3%. CONCLUSIONS: IABP malposition was commonly identified by CT. Reasons included incorrect proximal balloon position as well as an anatomic-to-balloon length mismatch. Thus, shorter than recommended balloon sizes and better positioning strategies had to be considered.

Facilitated anastomosis using a reverse thermo-sensitive polymer for temporary coronary occlusion in off-pump minimally invasive direct coronary artery bypass surgery.

To evaluate the safety and efficacy of a novel, reverse thermo-sensitive polymer (LeGoo™) for its ability to provide temporary coronary occlusion and hemostasis during minimally invasive direct coronary artery bypass (MIDCAB) surgery. Between January 2009 and March 2009, 20 consecutive MIDCAB patients were studied. Ten patients received a conventional MIDCAB procedure using proximal vessel loops and CO2 blower (control group). The following 10 patients were operated by an otherwise identical procedure, except that intracoronary administration of LeGoo™ was used instead of vessel snares (LeGoo™ group). Left internal mammary artery (LIMA) bypass flow, peri- and postoperative events and perioperative creatinine kinase-MB fraction (CK-MB) release were prospectively analyzed. CO2-blower use was required in three of 10 of the LeGoo™ patients. Procedural time was identical, with a trend of shorter anastomosis time in the LeGoo™ group (12.3 vs. 10.7 min, P=0.11). LIMA-LAD flow was also not different (control 35.8 vs. LeGoo™ 42.5 ml/min, P=0.541). CK-MB values were not statistically different on postoperative days 1 and 2. However, the level of CK-MB 4 h postoperatively was lower in LeGoo™ patients (18.3±6.1 vs. 13.2±2.9 U/l, P=0.006). No major adverse cerebral or cardiovascular event occurred postoperatively and during follow-up of 317±21 days. Using LeGoo™ to achieve temporary coronary artery occlusion is easier to work with during MIDCAB due to the absence of vessel snares and less need of blowing to eliminate blood from the operative field. There were no negative postoperative events associated with the use of LeGoo™.

[Coronary artery bypass surgery for the treatment of acute coronary syndromes]. / Stellenwert der koronaren Bypass operation in der Therapie der akuten Koronarsyndrome.

According to the current guidelines coronary revascularization in acute coronary syndromes (ACS) is primarily performed by percutaneous coronary interventions (PCI). However, in several scenarios like complex coronary pathologies, unsuccessful PCI, complicated PCI or cardiogenic shock, surgical coronary revascularization might be indicated. Then, timing of the operation is based on clinical symptoms, coronary artery pathology, and the type of underlying ACS (Figure 1). Surgical strategies among others include the use of beating-heart strategies. Furthermore, a modern perioperative management allows improved results in a more aged and comorbid patient population as well as in patients presenting with hemodynamic instability. In cardiogenic shock, a variety of different cardiopulmonary assist devices are available today including intra-aortic balloon pump, several ventricular assist devices, and extracorporeal membrane oxygenation (Figure 2).In the literature, results of coronary artery bypass grafting (CABG) in ACS patients vary significantly because of different patient populations, different timing of the operation, and different hemodynamic status. Thus, comparison of surgical concepts is almost impossible. Until today, randomized surgical trials for ACS patients are pending. However, hospital survival of > 95% is reported even in emergency CABG patients during the last 5 years (Table 1). For all surgical candidates a close and direct communication between interventionalist and cardiac surgeon is mandatory to early identify the best treatment strategy and to achieve best possible revascularization results.

Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock.

OBJECTIVE: Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after extracorporeal membrane oxygenation implantation are not well described. METHODS: Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantation (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses. RESULTS: Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% +/- 17.6%, logistic EuroSCORE was 21.6% +/- 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 +/- 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years. CONCLUSIONS: Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.

Does reasonable incomplete surgical revascularization affect early or long-term survival in patients with multivessel coronary artery disease receiving left internal mammary artery bypass to left anterior descending artery?

BACKGROUND: The objective was to evaluate the impact of complete revascularization (CR) versus reasonable incomplete surgical revascularization (IR) in others than left anterior descending artery territory on early and late survival in patients with multivessel coronary artery disease (CAD). METHODS AND RESULTS: During a 7-year period, 8.806 consecutive patients with multivessel CAD affecting the proximal left anterior descending artery or left main stem underwent sternotomy for isolated coronary artery bypass grafting including left internal mammary artery-left anterior descending artery bypass. A total of 936 patients (10.6%) had IR of the circumflex or right coronary artery territory. IR was based on the traditional classification. Follow-up was 3.5+/-2.2 years. Patient groups were comparable regarding age (CR 67.1 versus IR 67.6 years), ejection fraction (57.2% versus 57.5%), and logEuroscore (4.5% versus 4.5%). Patients receiving IR presented with more complex CAD. Mean number of distal anastomoses was 3.0+/-0.8 CR versus 2.4+/-0.6 IR. Operation time (176 versus 187 minutes) and cross-clamp time (52 versus 56 minutes) were longer in the IR group (P<0.001). Hospital mortality was 3.3% CR versus 3.2% IR (P=0.520). Independent risk factors for hospital mortality were age, pulmonary hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and emergency indication, but not IR (P=0.922). Arterial revascularization was protective. Cumulative survival at 1-year was 93.1% CR versus 93.6% IR and at 5 years 82.2 CR versus 80.9% IR (P=0.457). CONCLUSIONS: In presence of left internal mammary artery-to-left anterior descending artery bypass, reasonable IR of the circumflex or right coronary artery territory did not adversely affect early or long-term survival in patients with multivessel CAD. In patients presenting with 1 poor target vessel; however, IR is a good therapeutic option and the benefit of CR should be balanced against the risks.