Protruding coronary stent detected by transesophageal echocardiography changes surgical procedure.

This case describes an unusual intraoperative transesophageal echocardiogram (TEE) finding of an unknown sinus of Valsalva mass in a patient undergoing an off-pump coronary artery bypass procedure. The intraoperative TEE finding not only revealed a protruding right coronary ostial stent but also changed the surgical procedure to include an aortotomy that allowed successful removal of the stent. As interventional cardiologists begin exploring more techniques to manage difficult ostial lesions, this finding may be seen more commonly in the future. This case highlights how the use of routine TEE even in off-pump coronary artery bypass procedures may be very beneficial.

Intraoperative temperature control using the Thermogard system during off-pump coronary artery bypass grafting.

PURPOSE: Normothermia during off-pump coronary bypass (OPCAB) grafting reduces metabolic derangements and contributes to improved clinical outcomes. Thus study examined the feasibility and efficacy of intraoperative temperature control using a novel endovascular heating system during OPCAB. DESCRIPTION: Thirty-eight consecutive patients undergoing OPCAB were prospectively randomized to receive conventional warming (elevated room temperature, warmed intravenous fluids, warming blanket) or the Thermogard system (Alsius Corp, Irvine, CA). The triple-lumen temperature control Icy catheter (Alsius Corp) was inserted percutaneously into the inferior vena cava through common femoral vein. The catheter was removed after all wounds were closed. Temperature measurements (bladder, nasopharyngeal, and blood) were recorded at 5-minute intervals and compared between groups. EVALUATION: Patient demographics did not significantly differ between groups. The 17 Thermogard patients warmed at a significantly faster rate than the 21 control patients (0.28 degrees vs 0.11 degrees C/h, p = 0.03). Furthermore, Thermogard patients received more bypass grafts (3.4 +/- 0.6 vs 2.6 +/- 0.9, p < 0.001) and less intraoperative fluids (1557.0 +/- 547.7 vs 2012.3 +/- 723.1 mL, p = 0.02) despite longer operative times (150.3 +/- 123.4 vs 108.1 +/- 43.7 min; p = 0.12). All catheters were placed successfully on the first attempt, and there were no device-related complications. CONCLUSIONS: Endovascular warming is safe, simple to use, and obviates the need for uncomfortably warm operating room temperatures. The Thermogard system compared favorably with conventional methods for warming during OPCAB.

Thoracoscopic transmyocardial laser revascularization: is prior coronary artery bypass grafting a contraindication?

OBJECTIVE: : Recently, thoracoscopic techniques have been used to perform transmyocardial laser revascularization (TMR) in patients who are not suitable candidates for coronary artery bypass graft (CABG) surgery or percutaneous coronary interventions. Whether or not prior CABG contraindicates a port access-only approach to TMR is unclear. This study compares patients with and without prior CABG who have undergone thoracoscopic TMR. METHODS: : Between May 2003 and October 2005, 23 consecutive patients (6 without prior CABG, group A; and 17 with prior CABG, group B) underwent thoracoscopic TMR, using a holmium:yttrium-aluminum-garnet (Ho:YAG) laser system. Either 3 or 4 port incisions (each ≤2 cm in length) were used, depending on the patient's anatomy. Procedural success was defined as the ability to create all intended channels without conversion to thoracotomy. RESULTS: : Patient demographics were not significantly different between group A and group B (mean age, 65.8 ± 4.3 years versus 67.4 ± 2.4 years, Canadian Cardiovascular Society angina class 3.7 ± 0.2 versus 3.9 ± 0.1, and Parsonnet score 12.0 ± 3.2 versus 20.5 ± 2.4). Fourteen (82.4%) group B patients had a prior left internal mammary artery to left anterior descending artery graft, of which 12 (85.7%) were patent. One patient in group A had an airway injury at intubation that led to an extended hospital stay of 30 days. One patient in group A (16.7%) and one patient in group B (5.9%) required a blood transfusion (P = NS). Adhesion lysis time in group B ranged from 0 to 68 minutes (mean, 27 ± 5.6 minutes). Neither group had a conversion to thoracotomy or any deaths through a mean combined follow-up of 12 months. CONCLUSIONS: : A port access approach is safe and reproducible for patients who are candidates for sole therapy TMR. Prior CABG, including patent grafts, is not a contraindication to thoracoscopic TMR.

Mid-term results after thoracoscopic transmyocardial laser revascularization.

BACKGROUND: Transmyocardial revascularization is a surgical therapy for the relief of severe angina in patients who are not suitable candidates for coronary artery bypass graft surgery or percutaneous coronary interventions. Historically, surgical techniques employed a left thoracotomy with or without thoracoscopic assist for visualization. This study evaluated the feasibility and midterm outcomes after transmyocardial laser revascularization performed using a completely thoracoscopic, closed chest approach. METHODS: Patients (9 men [90%] and 1 woman [10%]) at a mean age of 66 +/- 10 years who were ineligible for coronary artery bypass graft surgery or percutaneous coronary intervention underwent sole therapy transmyocardial laser revascularization using a completely thoracoscopic surgical approach using a holmium:yttrium-aluminum-garnet laser system. Preoperatively, patients had a mean ejection fraction of 0.51 +/- 0.09 and a mean angina class of 3.7 +/- 0.5. RESULTS: A mean of 30 +/- 2.4 channels were created during mean laser and operative procedure times of 14 +/- 2.9 and 133 +/- 32 minutes, respectively. Patients were extubated at a mean of 7.6 +/- 12 hours and were discharged from the hospital at a mean of 5.4 +/- 3.4 days. There were no hospital deaths or major complications. At a mean of 8.4 +/- 5.5 months postoperatively, all patients survived and significant clinical improvement with a mean angina class of 1.3 +/- 0.5 (p < 0.001). CONCLUSIONS: A completely thoracoscopic surgical approach is feasible for sole therapy transmyocardial revascularization that affords improved visualization over a limited thoracotomy approach. Limited complications and significant clinical improvement after the procedure were observed. With minimal port manipulation, there is an opportunity for decreased postoperative pain; however, larger studies are warranted to verify this hypothesis.