A Surgical Technique to Preserve the Subvalvular Apparatus in Patients Undergoing Mitral Valve Replacement for Severe Ischemic Regurgitation

ABSTRACT Severe functional mitral valve regurgitation should be treated in patients undergoing myocardial revascularization. When replacement is considered the best therapeutic option, preservation of the mitral subvalvular apparatus is crucial, especially in the emergency setting, because of its primary role in preserving geometry and function of left and right ventricles. Here we present a simple and quick technique, where subvalvular apparatus is preserved in toto in patients undergoing mitral valve replacement with a bioprosthesis.

A Surgical Technique to Preserve the Subvalvular Apparatus in Patients Undergoing Mitral Valve Replacement for Severe Ischemic Regurgitation.

Severe functional mitral valve regurgitation should be treated in patients undergoing myocardial revascularization. When replacement is considered the best therapeutic option, preservation of the mitral subvalvular apparatus is crucial, especially in the emergency setting, because of its primary role in preserving geometry and function of left and right ventricles. Here we present a simple and quick technique, where subvalvular apparatus is preserved in toto in patients undergoing mitral valve replacement with a bioprosthesis.

Usability, performance and safety of a new device for degenerative mitral regurgitation: in vivo chronic evaluation.

OBJECTIVES: This study aimed to evaluate the usability, performance and safety of an innovative mitral valve device in the chronic setting characterized by an intraventricular bridge, which enables artificial chordae anchoring and/or direct posterior leaflet fixation. METHODS: Ten female sheep were employed and underwent device implantation. Any interference of the device with leaflet motion, ease of device use, correct chordae length estimation and implantation were evaluated. Post-procedural valve competence and device performance were verified by periodic postoperative echocardiograms and laboratory examinations. Following euthanasia, gross anatomy and histology evaluation of the hearts and valves were performed to detect tissue abnormalities and inflammation reaction related to the device. RESULTS: The procedure was successfully completed in all 10 sheep. Lengths of the 2 chordae implanted were 23 (21.5-24) mm and 23 (22.5-24) mm. The time required to suture both pairs of the artificial chordae was 2.7 ± 0.7 min. At the 3-month follow-up, left ventricular function was normal. The transvalvular peak pressure gradient was 9 (7.5-10) and the mean gradient was 4 (3.5-4) mmHg. Upon necropsy and histological evaluation, no damage to left ventricle wall, valve leaflets, chordae and papillary muscles and absence of thrombus formation and inflammatory reaction were observed. Radiological images showed neither fracture of the device nor calcifications. Laboratory tests showed no signs of haemolysis. CONCLUSIONS: In vivo late tests confirmed the ease of correct chordal length estimation prior to implantation, short operative time and usability in flailed anterior leaflet repair. The absence of negative impact of the device on mitral leaflets motion, function and structure and successful repair might suggest that the device would be useful in complex degenerative mitral disease.

Pectoralis Muscle Flap Repair Reduces Paradoxical Motion of the Chest Wall in Complex Sternal Wound Dehiscence.

BACKGROUND: The aim of the study was to test the hypothesis that in patients with chronic complex sternum dehiscence, the use of muscle flap repair minimizes the occurrence of paradoxical motion of the chest wall (CWPM) when compared to sternal rewiring, eventually leading to better respiratory function and clinical outcomes during follow-up. METHODS: In a propensity score matching analysis, out of 94 patients who underwent sternal reconstruction, 20 patients were selected: 10 patients underwent sternal reconstruction with bilateral pectoralis muscle flaps (group 1) and 10 underwent sternal rewiring (group 2). Eligibility criteria included the presence of hemisternum diastases associated with multiple (≥3) bone fractures and radiologic evidence of synchronous chest wall motion (CWSM). We compared radiologically assessed (volumetric computed tomography) ventilatory mechanic indices such as single lung and global vital capacity (VC), diaphragm excursion, synchronous and paradoxical chest wall motion. RESULTS: Follow-up was 100% complete (mean 85±24 months). CWPM was inversely correlated with single lung VC (Spearman R=-0.72, p=0.0003), global VC (R=-0.51, p=0.02) and diaphragm excursion (R=-0.80, p=0.0003), whereas it proved directly correlated with dyspnea grade (Spearman R=0.51, p=0.02) and pain (R=0.59, p=0.005). Mean CWPM and single lung VC were both better in group 1, whereas there was no difference in CWSM, diaphragm excursion and global VC. CONCLUSION: Our study suggests that in patients with complex chronic sternal dehiscence, pectoralis muscle flap reconstruction guarantees lower CWPM and greater single-lung VC when compared with sternal rewiring and it is associated with better clinical outcomes with less pain and dyspnea.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience.

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch (P=0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P=0.002), body mass index >30 kg/m2 (OR=9.9; 95% CI, 1.28-19; P=0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P=0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P=0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% (P=NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures.

BACKGROUND: The aim of this study was to evaluate 10-year results of same-day hybrid revascularization of concomitant carotid artery disease by stenting (CAS) and coronary artery disease by coronary artery bypass grafting (CABG), later also applied to patients requiring CAS and other than coronary open heart cardiac surgery. METHODS: One hundred thirty-two consecutive patients (70 ± 8 years, 102 men) underwent same-day CAS and CABG (group 1, n = 97) or other cardiac surgical procedures (aortic ± mitral valve surgery ± ascending aorta replacement ± CABG; group 2, n = 35). In both groups aspirin (100 mg daily) was started 2 days before CAS and permanently continued; clopidogrel, 300 mg initially followed by 75 mg daily, was started 6 hours after surgery and discontinued 1 month later. In group 2, when required, warfarin was started and aspirin discontinued on the second postoperative day. Mean follow-up was 53 ± 24 months. RESULTS: Overall in-hospital mortality was 3.8% (2.1% in group 1 versus 8.6% in group 2; p = 0.02; 0% for noncoronary isolated procedures, 20% for complex cases), perioperative myocardial infarction was 0%, and stroke was 0.75% (0% in group 1 versus 2.86% in group 2; p = 0.26). Late survival was 81% ± 10% (92% ± 3.2% in group 1 versus 80% ± 11% in group 2; p = 0.45), and overall freedom from neurologic events was 84% ± 6%. CONCLUSIONS: Same-day hybrid approach appeared safe in terms of early and long-term results not only for CAS and isolated CABG but also for CAS and noncoronary isolated procedures. In complex cases, the rate of stroke and myocardial infarction seemed low; in-hospital mortality, as expected, was higher. Long-term survival appeared similarly satisfactory, thus confirming the hybrid approach as a valid therapeutic option for all patients with significant internal carotid artery stenosis associated with coronary and other cardiac lesions, at least for noncomplex cases.

The fate at mid-term follow-up of the on-pump vs. off-pump coronary artery bypass grafting surgery.

AIMS: To evaluate the fate of on-pump coronary artery bypass grafting (ON-pump CABG) vs. off-pump coronary artery bypass grafting (OP-CABG) surgery at mid-term follow-up. METHODS: From January 2008 to December 2010, 369 patients underwent surgical myocardial revascularization by means of OP-CABG techniques (n = 166) or with ON-pump CABG (n = 203). Data of the two groups of patients were retrospectively analyzed. RESULTS: As compared with OP-CABG, in the ON-pump CABG patients, mean value of Logistic EuroSCORE (8.1 ± 7.8% vs. 6.2 ± 5.9%, P = 0.04), more extended coronary disease (2.7 ± 0.5 vs. 2.5 ± 0.7 diseased vessels/patient, P < 0.001) consequently requiring greater number of grafts/patient (2.9 ± 0.9 vs. 2.3 ± 0.9, P < 0.0001), and emergency surgery (12 vs. 6%, P = 0.03) were more frequently observed. Operative mortality was 1.9% in ON-pump CABG vs. 1.2% in OP-CABG (P = 0.6) and incidence of stroke 2.46 vs. 1.81% (P = 0.7). The incidence of stroke was reduced at 1.2% when OP-CABG PAS-Port 'clamp-less' technique was used.Intraoperatively, costs per patient were higher for OP-CABG vs. ON-pump CABG (1.930,00 +1.050,00 €, if PAS-port system was included, vs. 1.060,00 € for ON-pump surgery). ICU stay (1.9 ± 1.0 days vs. 1.4 ± 0.7 days) and total postoperative in-hospital stay (5.3 ± 3.3 days vs. 5.5 ± 3.5 days) were similar in both groups.At 4 years, survival (91 ± 13% in the ON-pump CABG vs. 84 ± 19% in the OP-CABG), freedom from major adverse cardiac events (composite end-point of all-cause death, myocardial infarction, and repeat coronary revascularization of the target lesion) (82 ± 9% vs. 76 ± 14%), and major adverse cardiac and cerebrovascular events (80 ± 11% vs. 72 ± 16%) were not significantly different. Freedom from late cardiac death was slightly significant higher after ON-pump CABG (98 ± 4% vs. 90 ± 10%, P = 0.05). CONCLUSION: Mid-term freedom from composite end-points is similar after ON-pump CABG and OP-CABG. Freedom from cardiac death appears to be better after ON-pump CABG. OP-CABG needs for more expensive surgical technique. OP-CABG performed by an experienced surgical team using 'clamp-less' techniques can be an effective strategy in reducing postoperative stroke.

Surgical approach to aortic valve replacement after previous bilateral internal thoracic artery grafting.

The authors present a manubrium-sparing sternotomy technique for aortic valve replacement in patients who have undergone previous myocardial revascularization with both internal thoracic arteries. They have found that preoperative 64-multislice computed tomographic imaging facilitates surgical planning by delineating the course of patent grafts and, in particular, the relationship between the sternum and the right internal thoracic artery graft. A manubrium-sparing sternotomy can in such instances avoid injury to the right internal thoracic artery graft during both resternotomy and adhesion dissection, thus reducing surgical risk and operative time.

Hybrid approach to treat total thoracic aortic aneurysm in a patient undergoing emergency surgery for descending aortic rupture.

Rupture of the descending aorta is a life-threatening complication requiring emergency intervention. The endovascular approach (TEVAR) has been recently introduced to treat the descending aorta in the emergency setting, resulting in better early postoperative outcome as compared with traditional surgery. However, when the pathology involves the aortic arch and ascending aorta, TEVAR alone cannot be performed, requiring an alternative approach. We describe a one-stage hybrid repair via midline sternotomy to treat rupture of the descending thoracic aortic segment in toto.

Early and long-term results of pectoralis muscle flap reconstruction versus sternal rewiring following failed sternal closure.

OBJECTIVES: The aim of the study was to compare early and long-term results of pectoralis muscle flap reconstruction with those of sternal rewiring following failed sternal closure. Primary outcomes of the study were survival and failure rate. Respiratory function, chronic pain and quality of life were also evaluated. METHODS: In a propensity-score matching analysis, of 94 patients who underwent sternal reconstruction, 40 were selected; 20 underwent sternal reconstruction with bilateral pectoralis muscle flaps (Group 1) and 20 underwent sternal rewiring (Group 2). Survival and failure rates were evaluated by in-hospital records and at follow-up. Respiratory function measures, including vital capacity (VC), were evaluated both by spirometry and computed tomography (CT) volumetry. Chronic pain was evaluated by the visual analogue pain scale. RESULTS: At 85 ± 24 months of follow-up, survival and procedure failure were 95 and 90% in Group 1 and 60 and 55% in Group 2, respectively (P < 0.01, for both comparisons). Based on CT-scan volumetry, in Group 1, severe non-union and hemisternal paradoxical movement occurred less frequently (2 vs 7, P = 0.01). At spirometry assessment, postoperative VC was greater in Group 1 (3220 ± 290 vs 3070 ± 290 ml, P = 0.04). The same trend was detected by CT-scan in-expiratory measures (4034 ± 1800 vs 3182 ± 862 mm(3), P < 0.05). Correspondingly, in Group 1, less patients presented in NYHA Class III (P < 0.05), and both chronic persistent pain score and physical health quality-of-life score were significantly better in the same group. CONCLUSIONS: In our study, muscle flap reconstruction guaranteed better early and late-term results as shown by lower rates of mortality, procedure failure and hemisternum stability. Moreover, Group 1 patients had greater postoperative VC, lower NYHA class and better quality of life. These results suggest that, in patients with multiple bone fracture, the rewiring approach does not promote physiological bone consolidation, whereas the muscle flap reconstruction can assure more physiological ventilatory dynamics.

Alternative surgical approach to treat aortic arch aneurysm after ascending aortic replacement with hybrid prosthesis.

We present a surgical technique to treat the distal aortic arch in patients who previously underwent ascending aortic replacement using the frozen elephant trunk. After debranching of the epiaortic vessels using a custom-made four-branch graft and systemic cooling, the extracorporeal circulation is interrupted, maintaining antegrade cerebral perfusion through the four-branch prosthesis. Then the "old" Dacron prosthesis, previously implanted for the ascending aortic replacement, is partially incised at its distal end, leaving a margin of prosthesis anastomosed to the native distal aorta, and the E-vita stent-graft is deployed under direct vision. Then the two margins of the "old" Dacron and the new Dacron E-vita prosthesis (Jotec Inc., Hechingen, Germany) are sutured together with one suture line to guarantee sealing and reconstruction of the aorta. This technique presents several advantages: the discrepancy between the graft size and the native aortic diameter is avoided, performing the anastomosis between two prosthetic materials with similar diameters is easier; there is no risk of tears in the diseased native aortic wall and related bleeding; and finally, it is easier to perform the anastomosis at the level of the ascending aorta rather than at the distal arch, especially when the disease of the aorta is extended to the descending segment.

Acute left hemothorax as a late complication of an active-fixation pacemaker lead.

Perforation and migration of pacemaker electrodes into the pleural cavity is a rare event. We report the clinical course and surgical treatment of massive acute hemothorax resulting from intercostal artery laceration, caused by a retained active-fixation pacing lead implanted 10 months earlier.

Left atrial radiofrequency ablation associated with valve surgery: midterm outcomes.

BACKGROUND: Left atrial ablation is a surgical standard technique for the treatment of persistent or chronic atrial fibrillation (p-AF and c-AF, respectively).Objective The aim of the study is to evaluate midterm results of left atrial ablation according to modified Maze procedure in patients affected by p-AF or c-AF and concomitant mitral or aortic valve disease requiring surgical treatment. METHODS: A total of 108 patients (age, mean ± standard deviation [SD]: 66 ± 8.5 years) underwent left atrial ablation by means of unipolar (n = 62) or bipolar (n = 66) radiofrequency for p-AF (n = 28) or c-AF (n = 100) in association with mitral (n = 93) or mitral and aortic valve (n = 35) surgery. RESULTS: In-hospital mortality was 0.8%. Patients with preoperative c-AF had preoperative greater value of left atrial diameter (56.7 ± 7.4 vs. 52 ± 9 mm, p = 0.05) than those with p-AF. At 9 years after Maze procedure, 86% (n = 24/28) of patients with preoperative p-AF were in sinus rhythm versus 28% (n = 27/95) with c-AF (p < 0.0001). Preoperative c-AF and left atrial diameter of 75 mm or more predicted atrial fibrillation recurrence. In patients in sinus rhythm compared with those in residual atrial fibrillation, survival was 100 versus 86% ± 6.4%, New York Heart Association class was 1.3 ± 0.5 versus 1.7 ± 0.6, and need of lifelong anticoagulation therapy was 43 versus 91% (p < 0.05, for all comparisons). CONCLUSIONS: Left atrial Maze procedure for p-AF offers better chances to conversion in sinus rhythm as compared with long-standing c-AF. Survival, functional status, and quality of life are superior in patients who benefit from sinus rhythm.

Survival and durability of mitral valve repair surgery for degenerative mitral valve disease.

AIM OF THE STUDY: To evaluate the results after standardized techniques of mitral valve repair (MVr) for treatment of degenerative mitral regurgitation (MR) and to analyze risk factors for late outcomes. METHODS: Two hundred and sixty-one patients (mean age 63 ± 12 years) underwent MVr between January 1999 and January 2010 for degenerative MR. In the last five years, all repair techniques were performed routinely using annuloplasty prosthetic ring, with or without quadrangular or triangular resection of posterior leaflet and/or edge-to-edge technique as always indicated by intraoperative transesophageal echocardiography. Mean follow-up (99% complete) was 54 ± 38 (range, 6 to 137) months. RESULTS: Operative mortality was 0.8% (2/261), 10-year actuarial survival 89%± 3%. At 10 years of follow-up freedom from cardiac death was 94%± 2.6%, from reoperation 95%± 2.4%, from thromboembolism 96%± 2.1%, and from endocarditis 100%. Independent predictor of late all-causes mortality was advanced age at operation (71 ± 10 years vs. 62 ± 12 years, p = 0.0068). Late progression to moderate or severe MR was observed in 12/256 patients (4.7%). Independent predictor of late progression to moderate or severe MR was annuloplasty without the use of prosthetic ring (p = 0.04). Reoperation was required in six patients (2.3%). Follow-up echocardiography showed improvement of MR, left ventricular end-diastolic and end-systolic diameters, left atrial diameter, and systolic pulmonary artery pressure (p < 0.0001 for all comparisons with preoperative values). CONCLUSIONS: MVr is a low-risk, durable surgical procedure. Standardized techniques, with the routine use of prosthetic ring, improve late results.

Performance of a novel sternal synthesis device after median and faulty sternotomy: mechanical test and early clinical experience.

BACKGROUND: Reinforcement of chest closure may be required in patients with multiple risk factors of wound dehiscence. Performance of a light, size-adaptable closure reinforcement device (DSS: Sternal Synthesis Device; Mikai SpA, Vicenza, Italy) is presented. METHODS: A longitudinal median or paramedian incision was performed in artificial sternal models: closure was accomplished with simple interrupted steel wires or reinforced with the DSS. Forces required for separation of the rewired sternal halves during a monotonic tensile test were analyzed. A high velocity traction cycles test was also adopted to simulate the impact of coughing. RESULTS: After median incision, ultimate load values inducing break of the sternum models were 580 +/- 35 N (Newton) in controls; failure of the test occurred at 1,200 +/- 47 N in the reinforced group (p = 0.0002). More lateral displacement of sternal halves at increasing forces was observed in controls (p = 0.0001). After paramedian incision, ultimate load values inducing break of the constructs were lower in controls (220 +/- 20 N vs 500 +/- 25 N, p = 0.001), which also showed more lateral displacement of sternal halves than the reinforced group (p = 0.002). At the high velocity traction cycles test, the number of cycles required to break the models was lower in controls (2,250 +/- 35 vs 3,855 +/- 48 cycles, p = 0.0001). Preliminary clinical experience in 45 patients showed ease of implantation and low risk of complications. CONCLUSIONS: The proposed sternal reinforcement device provides substantial sternal support at electromechanical testing after median and faulty sternotomy and may hopefully prevent sternal wires migration and bone fractures in high risk patients.

[Surgery for type A aortic dissection: long-term results and risk factor analysis]. / La chirurgia della dissecazione acuta dell'aorta: risultati a lungo termine e fattori di rischio.

BACKGROUND: Identification of risk factors may help prevent mortality and recurrence after surgical treatment of type A aortic dissection. METHODS: From January 1995 to March 2006, 100 consecutive patients (82 men, 18 women, mean age 58 +/- 12 years) with type A acute aortic dissection were submitted to replacement of ascending aorta (n = 62), arch (n = 27), or the aortic root (n = 11, 9 with the Bentall operation and 2 with the David aortic valve reimplantation). Patients were followed up for 48 +/- 33 months (range 1-120 months). RESULTS: Operative mortality was 18% for aortic root replacement, 24% for ascending aorta replacement, 26% for arch replacement, respectively (p = NS). Independent risk factors for operative mortality were: acute (p = 0.001) and chronic renal dysfunction (p = 0.02), advanced patient age (61 +/- 13 vs 56 +/- 13 years, p = 0.02), prolonged bypass time (p = 0.01). Antegrade cerebral perfusion and moderate hypothermia during arch replacement was associated with better results than deep hypothermia (mortality 0/12 vs 7/15 patients, p = 0.008). Eight-year survival and freedom from cardiovascular events were 74 +/- 7.5% and 70 +/- 7.4%, respectively. Independent risk factor for late death was left ventricular ejection fraction < 0.50 (p = 0.02). Five out of 67 patients (7.5%) submitted to replacement of the ascending aorta with a tubular graft, who presented a dilated aortic root diameter (47 +/- 3.4 vs 40.4 +/- 4.9 mm, p = 0.004), were reoperated for proximal progression of the disease into the native aortic root (dilation n = 3, dissection n = 2) after 33 +/- 20 months (range 2-58 months). Proximal aorta reoperation was associated with markedly reduced 8-year survival (52 +/- 23 vs 82 +/- 7%, p = 0.017). CONCLUSIONS: Surgery for acute aortic dissection represents an emergency treatment with satisfactory long-term results. Survival is affected by renal dysfunction at presentation, which should be aggressively treated, and by progression of the disease requiring reoperation; a dilated diameter of the aortic root should therefore indicate root replacement at the time of first operation.

Sequential hybrid carotid and coronary artery revascularization: immediate and mid-term results.

BACKGROUND: To minimize event rates in patients with elevated cardiovascular surgical risk, we investigated a new therapeutic strategy consisting of simultaneous hybrid revascularization by carotid artery stenting (CAS), immediately followed by coronary artery bypass grafting (CABG). METHODS: The study included 37 patients with severe carotid and coronary artery disease and a European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 5 or higher. Immediately after CAS, patients underwent CABG. The primary end point was the incidence of stroke, myocardial infarction, or death at 30 days. Secondary end points were a combination of transient ischemic attack, major local complications, bleeding, and systemic complications within the 30 days after treatment, and any stroke, acute myocardial infarction, or death from day 31 through to the end of the follow-up. All clinical outcomes were assessed by an independent monitoring board. RESULTS: The rate of procedural success was 97.3%. The 30-day cumulative incidence of disabling stroke, myocardial infarction, or death was 8.1%: 2 patients (5.4%) died, and 1 patient had a stroke immediately after carotid stenting. Another patient died between day 31 and 6 months after the intervention. CONCLUSIONS: Our findings indicate that in elevated-surgical-risk patients with carotid stenosis and coronary artery disease suitable for CABG, hybrid revascularization by CAS, immediately followed by CABG, is a feasible and promising therapeutic strategy.

Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting.

Surgical treatment of simultaneous coronary and carotid disease is still controversial, because of the high risk of morbidity and mortality after combined or staged carotid artery endoarterectomy and the coronary artery bypass grafting approach. We report the first 10 patients with concomitant coronary and carotid disease successfully treated with an alternative strategy consisting of simultaneous hybrid revascularization by carotid artery stenting and coronary artery bypass grafting.

Thrombosis of the left anterior descending artery due to compression from giant pseudoaneurysm late after a bentall operation.

BACKGROUND: A postoperative pseudoaneurysm may develop and gradually expand in the mediastinal space even late following Bentall operation for aortic root replacement, particularly in patients with dissection of the aorta. METHODS: A very large (148 mm) pseudoaneurysm originating of the right coronary ostium suture line was observed in a patient admitted with unstable angina 6 years after Bentall procedure for type A aortic dissection. Angiograms showed reduced flow in the right coronary and thrombotic subocclusion of the left anterior descending (LAD) coronary artery due to extrinsic compression from the expanding mediastinal mass. RESULTS: Reoperation was performed during femoro-femoral cardiopulmonary bypass and brief period of circulatory arrest to clamp the tubular graft. After closure of the detected right coronary ostium in the tubular graft double bypass, grafting to the right coronary and LAD arteries was required. Postoperative course was uneventful. CONCLUSIONS: Close long-term follow-up after a Bentall procedure is required to minimize the risk of developing a large pseudoaneurysmal mass, in particular, after dissection of the aorta.

Benefit of partial right-bilateral internal thoracic artery harvesting in patients at risk of sternal wound complications.

BACKGROUND: Excellent long-term patency of the internal thoracic artery (ITA) graft promotes use of bilateral ITA bypass grafting; sternal devascularization, however, increases the risk of wound complications. We hypothesized that restricting right ITA (RITA) harvesting to a short proximal skeletonized segment (3 to 5 cm) would result in adequate residual blood supply to reduce that risk. METHODS: Seventy-eight patients with numerous risk factors for wound complications underwent composite double ITA grafting, utilizing the RITA segment anastomosed to the left skeletonized ITA and to the obtuse marginal branch in Y fashion. Blood flow in the distal RITA was assessed by parasternal transthoracic Doppler ultrasonography. Comparisons were made with prospectively collected data of patients undergoing pedicled single (n = 160) or skeletonized bilateral ITA grafting (n = 143) during the same period. RESULTS: Incidence of obesity, chronic obstructive pulmonary disease, diabetes, and peripheral vascular disease was higher in study patients. Postoperative Doppler ultrasonography detected reversed systolic dominant flow pattern. Wound complications occurred in 2 of 78 (2.6%) patients, compared with 14 of 143 (9.8%) after bilateral ITA (p = 0.04) and 8 of 160 (5%) after single ITA grafting (p = ns). Technique of bilateral ITA harvesting (partial right versus full length; odds ratio, 0.2; confidence interval: 0.04 to 0.9) and diabetes mellitus (odds ratio, 2.7; 95% confidence interval: 1.1 to 6.3) were independent predictors of wound complications in the entire series. CONCLUSIONS: Substantial residual blood supply is detectable after partial RITA harvesting and may prevent wound complications in high-risk patients.