Left Atrial Appendage Exclusion Using the AtriClip Device: A Case Series.

BACKGROUND: Atrial fibrillation (AF) affects 1.5-2% of the population and is associated with a five-fold increased lifetime risk of stroke [1]. The left atrial appendage (LAA) is the source of embolic strokes in up to 90% of patients with non-valvular AF with clots in the left atrium [2]. METHODS: We reviewed the clinical notes and echocardiographic findings of 20 patients who underwent open cardiac surgery in which concurrent AtriClip (Atricure Inc, Westchester, OH, USA) device insertion was attempted at our institution from July 2013 to February 2015. This was to examine the safety and efficacy of LAA exclusion with clip devices during open cardiac surgery. Indications for LAA exclusion included a history or suspicion of atrial arrhythmia, left ventricular dilatation, or a history of transient ischaemic attacks. RESULTS: All 20 of the 20 participants had successful placement of the clip device (100% success rate). There were no adverse events related to the device and no perioperative mortality. There were three late deaths due to chronic obstructive pulmonary disease (COPD), leukaemia, and refractory congestive cardiac failure. No late device related complications were found on follow-up imaging in the remaining patients. CONCLUSIONS: The results of our study demonstrate the LAA exclusion during open cardiac surgery with the AtriClip device is safe, has a 100% success rate, and appears to be stable over time.

Factors affecting patency of internal thoracic artery graft: clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002.

OBJECTIVE: The purpose is to define factors influencing long-term patency of the internal thoracic artery (ITA) to optimize the operative strategy. METHODS: 1482 left internal thoracic artery (LITA) and 636 right internal thoracic artery (RITA) symptom-directed angiograms were studied in 1434 patients. Data were prospectively collected from patients who had primary coronary artery bypass surgery during the period 1982-2002. The mean age of patients was 59 years; 85% were male. The mean period from operation to re-angiogram was 80 months. LITA was grafted to left anterior descending coronary artery (LAD) in 82% of cases, RITA to right coronary artery (RCA) in 40% and circumflex artery in 35% of cases. Graft failure was defined as > or =80% stenosis. RESULTS: 96.3% of LITA and 88.1% of RITA grafts were patent. No patient variables were significantly associated with graft patency (age, gender, diabetes, hypertension, LVEF, NYHA, AMI). Target coronary artery was associated with patency of both LITA and RITA grafts with maximum patency when grafted to LAD (P = 0.02) RITA had the worst patency to RCA, patency for the left system was identical to LITA. Proximal anastomosis to aorta (free RITA) had significantly better patency when compared with in situ RITA to RCA system (P = 0.005) while similar patency when grafted to left system. ITA diameter and target artery diameter were not associated with graft patency. Recent operations had better RITA patency (P = 0.03). The interval from operation to angiogram was not associated with ITA patency (96% patency for LITA and 88% patency for RITA, remained stable when studied at <1, 1-4, 5-9, 10-14 and >15 years). CONCLUSIONS: Even in a patient cohort that had adverse symptoms, excellent LITA and RITA patency was achieved which almost remained constant through all time intervals studied.

Patency of the radial artery graft: angiographic study in 209 symptomatic patients operated between 1995 and 2002 and review of the current literature.

OBJECTIVES: The purpose of this study is to define the long-term patency of the radial artery (RA) graft and review the current literature. METHODS: Two hundred and eighty-six RA symptom-directed graft angiograms were studied in 209 patients. The preoperative patient characteristics and intraoperative variables were collected prospectively from patients who had primary coronary artery bypass grafting between 1995 and 2002. A total of 166 (79%) patients were male with a mean age of 65 years. The mean period from operation to re-angiogram was 35 months. Actuarial techniques are not valid in graft patency studies as the time when the graft occluded is not known. Therefore, RA patency was analyzed at four categorical time intervals. The RA was grafted to the left anterior descending artery (LAD) in six patients (2%), diagonal (DIAG) in 29 (10%), obtuse marginal (OM) in 166 (58%), right coronary artery (RCA) in 9 (3%) and posterior descending artery (PDA) in 76 (27%) cases. The graft failure was defined as >or=80% stenosis. RESULTS: A total of 259 (91%) grafts were patent and 26 (9%) had failed. Most grafts were widely patent or occluded. The LAD/DIAG patency was 30/35 (86%), OM patency 154/166 (93%) and RCA/PDA patency 79/84 (94%). The interval from surgery to angiogram did not affect the RA graft patency (86% at <1 year, 95% at 1-3 years, 89% at 4-5 years, 96% at >5 years). CONCLUSIONS: Even in a patient cohort with adverse symptoms, excellent RA patency was achieved that remained almost constant through all time intervals studied. Better selection, harvesting and preservation may further improve early patency.

Factors affecting saphenous vein graft patency: clinical and angiographic study in 1402 symptomatic patients operated on between 1977 and 1999.

BACKGROUND: The purpose of this study was to find the preoperative and intraoperative factors that affect vein graft patency. METHODS: A total of 3715 graft angiograms in 1607 patients were studied for recurrence of angina. The preoperative patient characteristics and intraoperative variables were prospectively collected from patients who had primary coronary artery bypass grafting during the period from 1977 to 1999. A total of 1339 (83%) patients were male, with a mean age of 59 years. The mean period from operation to reangiogram was 99 months. The saphenous vein was grafted to the left anterior descending artery in 557 (15%), to the diagonal artery in 669 (18%), to the obtuse marginal artery in 1300 (35%), to the right coronary artery in 409 (11%), and to the posterior descending artery in 780 (21%) cases. Graft failure was defined as >or=80% stenosis. RESULTS: During the course of the study, 2266 (61%) grafts were patent, and 1449 (39%) had failed. The patient variables that significantly reduced graft patency were a younger age (P <.001) and an ejection fraction <30% (P =.047). Operative variables associated with reduced graft patency were small coronary artery diameter (P <.001), large conduit diameter (P =.001), and the coronary artery grafted (lowest patency in the right coronary artery and maximum patency in the left anterior descending artery territory; P =.002). The interval from operation to repeat angiogram (P <.001, with 78% patent at 1 year, 78% at 5 years, 60% at 10 years, and 50% at 15 years) and the year in which the operation was performed (more recent operations had better patency; P <.001) significantly affected graft patency. CONCLUSIONS: Saphenous vein graft patency improved over the course of the study. The best results were obtained in older patients with good left ventricular function. Large-caliber arteries on the left system, when grafted with a small-diameter vein, were associated with the best outcome.

Survival after myocardial revascularization for ischemic cardiomyopathy: a prospective ten-year follow-up study.

OBJECTIVE: The aim was to prospectively analyze all-cause mortality, predictors of survival, and late functional results after myocardial revascularization for ischemic cardiomyopathy over a 10-year follow-up. METHODS: We prospectively studied 57 patients with stable coronary artery disease and poor left ventricular ejection function (<35%), enrolled between 1989 and 1994. Stress thallium was analyzed in 37 patients to identify reversible ischemia. To avoid patients with a stunned myocardium, we excluded those with unstable angina or myocardial infarction within the previous 4 weeks. Mean age of the patients was 67 +/- 8 years, and 93% of patients were men. Mean left ventricular ejection fraction was 0.28 +/- 0.04, 50% were in Canadian Cardiovascular Society angina class III-IV, and 65% were in New York Heart Association functional class III-IV. RESULTS: Operative mortality was 1.7% (1/57). The mean left ventricular ejection fraction (0.30) at 15 months postoperatively did not change from before operation (0.28, P =.09). There were 8 deaths at 1 year and 42 deaths over the course of the study, producing a survival of 82.5% at 1 year, 55.7% at 5 years, and 23.9% at 10 years (95% confidence interval: 14.6%-39.1%). Symptom-free survival was 77.2% at 1 year and 20.3% at 10 years. The leading cause of death was heart failure in 29% (12/42). Multivariate analysis showed that large reversible defects on stress thallium were associated with improved left ventricular ejection fraction at 1 year (P =.01) but only male sex was associated with improved long-term survival (P =.036). CONCLUSIONS: Myocardial revascularization for ischemic cardiomyopathy is associated with good functional relief from the symptoms of angina initially and, to a lesser extent, heart failure. Revascularization may have the advantage of preserving the remaining left ventricular function. However, the long-term mortality remains high.

Radial artery patency and clinical outcomes: five-year interim results of a randomized trial.

OBJECTIVE: This study was undertaken to compare elective angiographic patency and cardiac event-free survival of the radial artery graft with that of the free right internal thoracic artery or saphenous vein during a 10-year period after primary coronary artery bypass surgery. METHODS: This prospective, randomized, single-center trial was conducted on two groups of patients undergoing primary coronary artery bypass surgery. In a younger group (group 1, n = 285, <70 years), the radial artery was compared with the free right internal thoracic artery. In an older group (group 2, n = 153, >/=70 years), the radial artery was compared with the saphenous vein. The trial conduit was grafted to the largest available coronary artery other than the left anterior descending coronary artery. Angiography was scheduled at intervals between 0 and 10 years according to a second random assignment. Patients were followed up at yearly intervals to assess clinical outcomes. Clinical outcomes were analyzed on an intent-to-treat basis during the 10-year follow-up with time-related analyses. This interim study reports angiographic and clinical outcome results during the first 5 years. RESULTS: Graft patency estimates were as follows: 0.95 (95% confidence interval 0.85-0.99) in 39 radial arteries versus 1.0 in 29 right internal thoracic arteries (P =.4) in group 1, and 0.86 (95% confidence interval 0.67-0.99) in 24 radial arteries versus 0.95 (95% confidence interval 0.83-0.99) in 22 saphenous veins (P =.5) in group 2. Cardiac event-free survival estimates were as follows: 0.91 (95% confidence interval 0.76-0.99) for the radial artery versus 0.82 (95% confidence interval 0.63-0.99) for the right internal thoracic artery (P =.7) in group 1, and 0.84 (95% confidence interval 0.64-0.99) for the radial artery versus 0.89 (95% confidence interval 0.72-0.99) for the saphenous vein (P =.9) in group 2. CONCLUSION: The 5-year interim results do not support the hypothesis that the radial artery has superior patency to or is associated with fewer clinical events than free right internal thoracic artery or saphenous vein grafts.