The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers.

OBJECTIVES: Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease. METHODS: It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy. RESULTS: Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9. CONCLUSIONS: Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.

Can Minimally Invasive Multivessel Coronary Revascularization Be a Routine Approach?

BACKGROUND: Advancement in the field of cardiovascular surgery has emerged with various minimally invasive approaches for the treatment of multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. This study describes our routine technical approach and clinical experience of minimally invasive coronary artery bypass via left anterior minithoracotomy for the treatment of patients with multivessel coronary lesions. METHODS: Our experience includes 100 consecutive patients who were operated between July 2020 and April 2021. The left internal thoracic artery was harvested in all patients. Radial arterial grafts and saphenous vein grafts were harvested endoscopically. Patients were operated either under cardiopulmonary bypass (CPB) with blood cardioplegia through left anterior minithoracotomy of 5 to 7 cm or off-pump via left anterolateral minithoracotomy. RESULTS: We had single mortality (1%), no early postoperative myocardial infarction was observed. None of our patients was converted to sternotomy (0%). The mean number of bypass was 3.1 ± 0.8, the mean cross-clamping time was 78.1 ± 20.6 minutes, the mean CPB time was 153.2 ± 37.5 minutes, the average intubation time was 6.33 ± 11.29 hours, the mean intensive care unit stay was 1.62 ± 1.78 days, the mean hospital stay was 4.98 ± 3.01 days, the average total operation time was 4.20 ± 0.92 hours, and the average pleural drain was 393.8 ± 169.7 mL. CONCLUSION: Minimally invasive coronary artery bypass grafting via left anterior minithoracotomy can be routinely performed with safety and it is feasible, reproducible with a short learning curve. Further multicenter studies are needed for the standardization of our technique.

Strategies and pitfalls during minimally invasive total coronary artery revascularization via left anterior minithoracotomy: a promising future.

For many years up to date coronary artery bypass surgery has been performed via sternotomy as a gold standard approach. However recently there has been alternative approaches for coronary artery bypass grafting in minimal invasive ways to reduce complications associated with sternotomy such as sternal wound infections, impared pulmonary functions and cosmetic related problems. Most of these minimal invasive procedures have been associated with long learning curve, high costs and sophiscated instruments used during surgery. Minimal invasive coronary artery bypass grafting via left anterior mini-thoracotomy is equally effective as a gold standard sternotomy with the same principles of suturing techniques and provides a great comfort in many aspects as sternotomy. It is safe and does not require sophiscated tools which require long learning curve and high expanses. This type of surgery requires the use of novel strategies, especially in patients who hold the highest potential for postoperative morbidity. In this paper, we will highlight the strategies and pitfalls associated with minimally invasive total coronary revascularization via left anterior minithoracotomy.

Minimal invasive approach of post-MI ventricular septal defect repair and coronary artery revascularization via left anterior minithoracotomy.

A 54-year-old male was admitted to our hospital with a prolonged dypsnea, orthopnoea, and chest pain that has lasted for almost 2 weeks. Physical examination revealed symptoms of heart failure. Transthoracic echocardiography revealed a ventricular septal defect located at the apical segment of the interventricular septum, mild mitral regurgitation, and hypokinesia of the apex of the left ventricle. Coronary angiography showed a critical proximal lesion of the left anterior descending artery. He was diagnosed with postmyocardial infarction ventricular septal defect. Our patient underwent minimal invasive coronary artery bypass and ventricular septal defect repair via left anterior minithoracotomy. Postoperative period was uneventful and our patient was released on a postoperative Day 7. Postoperative transthoracic echocardiography revealed no residue of repaired ventricular septal defect with improved left ventricular functions.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Detected by Echocardiography in an Asymptomatic Young Athlete.

The anomalous origin of the coronary artery from the pulmonary artery (ALCAPA) is the most common congenital coronary artery anomaly. Up to 90% of patients die during the first year of life. It is unusual for an ALCAPA patient to survive to adulthood. We present a case of an asymptomatic young athlete with ALCAPA, in which the diagnosis was established by echocardiography during pre-participation physical evaluation. The patient underwent surgical closure of the left main coronary artery ostium through the inside of the main pulmonary artery and coronary artery bypass grafting. He was discharged after 6 days and remained well during follow-up visits. We emphasize the importance of echocardiographic examination during pre-participation cardiovascular screening in young athletic populations to avoid sudden death related to ALCAPA.

Surgical Revascularization of the Left Anterior Descending Artery with Multiple Failed Overlapping Stents.

BACKGROUND: Multiple stents make standard coronary artery bypass techniques difficult. We describe our surgical approach, in patients undergoing coronary artery bypass grafting (CABG), in left anterior descending arteries (LAD) with multiple failed overlapping stents. METHODS: We retrospectively reviewed the data of six patients undergoing CABG with multiple failed overlapping stents in the LAD. All patients were operated on electively. After removal of the stents with an open endarterectomy, the long segmental arteriotomy of the LAD was reconstructed with a saphenous vein patch. Afterwards the left internal mammary artery was anastomosed to the vein patch. RESULTS: The mean age was 61.5 ± 7.9 years. Five patients (83.3%) were in Canadian Cardiovascular Society Class III or IV. Four patients (66.6%) had suffered a remote myocardial infarction (>1 month). The average hospital stay was 6.5 ± 1.1 days. Postoperative electrocardiograms showed no specific changes and no myocardial enzyme elevations were noted. Early postoperative angiography showed that all grafts including the endarterectomized LAD were patent. There was no mortality within the 30 days. Patients' mean follow-up time was 35.6 ± 36.7 months. CONCLUSIONS: CABG with open stent endarterectomy is a valuable alternative option for patients with "full-metal jacket" diseased LAD that are not graftable using standard surgical techniques.

Pretreatment with methylprednisolone improves myocardial protection during on-pump coronary artery bypass surgery.

BACKGROUND: This study was undertaken to determine whether methylprednisolone could improve myocardial protection by altering the cytokine profile toward an anti-inflammatory course in patients undergoing elective coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB). METHODS: Forty patients who were scheduled for elective CABG surgery were randomized into two groups: the study group (n = 20), who received 1 g of methylprednisolone intravenously before CPB, and the control group (n = 20), who underwent a standard CABG surgery without any additional medication. Blood samples were withdrawn prior to surgery (T1) and then 4 hours (T2), 24 hours (T3), and 36 hours (T4) after CPB. Plasma levels of interleukin (IL)-6, IL-10, creatine kinase isoenzyme MB (CK-MB), cardiac troponin-t (cTnT), and blood glucose as well as neutrophil counts were measured at each sampling time. RESULTS: A comparison of patients between both groups revealed significantly high levels of IL-6 in the control group at T2, T3, and T4 with respect to T1 (T2: P < .001; T3: P < .001; T4: P < .001). IL-10 levels were significantly higher in the study group at T2 compared with the control group (P = .007). CK-MB levels were significantly lower in the study group than in the control group at T4 (P = .001). The increase of cTnT was higher in the control group at T3 and T4 compared with the study group (T3: P = .002; T4: P = .001). CONCLUSIONS: This study demonstrates that methylprednisolone is effective for ensuring better myocardial protection during cardiac surgery by suppressing the inflammatory response via decreasing the levels of IL-6 and by increasing anti-inflammatory activity through IL-10.

Endovascular treatment of abdominal aortic aneurysm in a 26-year-old man. A case report and 10-year follow-up.

We present endovascular treatment of abdominal aortic aneurysm in a 26-year-old man with a 10-year follow-up. A young patient presenting with an abdominal aortic aneurysm is extremely rare, and data describing this population are limited. Open aneurysm repair (OAR) is the treatment of choice in these patients. However, since its introduction, endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. The long-term durability and late complications after EVAR may have more significance when considering the optimal treatment for young patients with a longer life expectancy. Our good long-term outcome will help to support the use of EVAR as a reasonable alternative to OAR in young patients with suitable anatomic findings.

Aspergillus flavus endocarditis of the native mitral valve in a bone marrow transplant patient.

BACKGROUND: Infective endocarditis due to Aspergillus species is an uncommon infection with a high mortality rate. It mostly occurs after the implantation of prosthetic heart valves. Parenteral nutrition, immunosuppression, broad-spectrum antibiotic regimens, and illegal intravenous drug use are the risk factors for developing infection. CASE REPORT: We report a case of Aspergillus flavus native mitral valve endocarditis in a patient who had allogeneic stem cell transplantation in the past due to myelodysplastic syndrome. CONCLUSIONS: Although it is rare and there is limited experience available with the diagnosis and treatment, early recognition and therapeutic intervention with systemic antifungal therapy and aggressive surgical intervention are critical to prevent further complications that may eventually lead to death. In addition, better novel diagnostic tools are needed to facilitate more accurate identification of patients with invasive Aspergillus and to permit earlier initiation of antifungal treatment.

Pinball-Like Free-Floating Left Atrial Ball Thrombus Presenting with Hemiplegia: A Challenging Treatment Decision.

We describe a case of a patient with a history of chronic atrial fibrillation who presented with sudden onset of left hemiplegia. Nine months earlier the longstanding warfarin therapy had been suspended due to a hemorrhagic stroke. Transthoracic echocardiography revealed a large free-floating highly mobile mass in the left atrium and severe mitral valve regurgitation. Due to the potential risk of an embolic event or a hemodynamic collapse, a decision to carry out an emergency operation was made irrespective of the neurological condition of the patient. Unfortunately, the patient died on the 18th postoperative day after a freshly occurring hemorrhagic stroke.

Extraanatomical coronary artery bypass grafting in patients with severely atherosclerotic (Porcelain) aorta.

BACKGROUND: Cannulation, cross clamping, or partial clamping of the aorta during a proximal anastomosis may cause embolic complications in patients with severely atherosclerotic (porcelain) aortas. These patients carry high morbidity and mortality risks due to intraoperative atheroembolism. METHODS: Between June 2008 and May 2010, 972 open heart surgery operations were performed in our department. In this group there were 41 patients who had severe atherosclerotic plaques in the aorta (porcelain aorta), and 9 of these underwent an extraanatomical coronary artery bypass grafting (CABG). These 9 patients were retrospectively analyzed and their demographic data, patient risk factors, and preferred surgical methods were reviewed. RESULTS: Seven patients underwent two-vessel CABG, while 2 underwent three-vessel CABG. Off-pump surgery was performed for 7 patients. CABG was performed with beating heart technique under cardiopulmonary bypass via femoral artery and right atrial cannulation without cross clamping in 2 of the patients. Postoperative course was uneventful in all patients. Mean length of stay in the intensive care unit was 2.11 ± 0.78 days. Mean hospitalization was 7.22 ± 0.97 days. Mean follow-up was 11.33 ± 3.67 months, and no cerebrovascular events were observed during this period. Postoperative evaluation of the grafts by multislice computed tomography revealed sufficient patency in all patients. CONCLUSIONS: Innominate artery is an alternative inflow source for the untouchable ascending aorta caused by severe atherosclerotic disease (porcelain aorta). In this group of patients, the risk of systemic embolisation and perioperative neurologic complications can be minimized by avoiding manipulation of the ascending aorta and using the innominate artery.

Extrinsic compression of the left main coronary artery: a case of atrial septal defect with enlarged pulmonary artery.

We report the case of an adult referred to our center with an initial diagnosis of stenosis of the left main coronary artery (LMCA). A preoperative investigation disclosed an atrial septal defect (ASD) with pulmonary artery hypertension. The angiographic studies confirmed the diagnosis and showed external compression of the LMCA by an enlarged pulmonary artery. Surgical closure of the ASD and tricuspid valve ring annuloplasty with coronary artery bypass surgery (left internal mammary artery to left anterior descending artery) were undertaken. Six months after the surgery, the patient is doing well.

Prosthetic valve implantation with preservation of the entire valvular and subvalvular apparatus of the tricuspid valve in congenitally corrected transposition of the great arteries.

Congenitally corrected transposition of the great arteries, which is characterized by atrioventricular and ventriculoarterial discordance, is a rare congenital heart disease. Most of the cases are diagnosed in childhood, owing to associated cardiac anomalies, such as ventricular septal defect, pulmonary stenosis or pulmonary atresia, and Ebstein-like malformation of the tricuspid valve. We present a patient with congenitally corrected transposition of the great arteries who underwent surgical replacement of the tricuspid valve with a bioprosthesis and reconstruction of the left ventricular outflow tract with bovine conduit.

Coronary artery bypass surgery in a patient with analbuminemia.

Congenital analbuminemia is a rare autosomal recessive disorder characterized by the absence of serum albumin, or by its presence in very low concentrations. Up to now, only 43 cases have been reported. There is little information about analbuminemia, and no operation on an analbuminemic patient has been reported. This, we believe, is the 1st report of an operation on an analbuminemic patient for coronary artery disease in which the perioperative experience is presented.

Mycotic ascending aortic pseudoaneurysm at aortic cannulation site.

Mycotic aneurysm of the aorta is a rare but highly fatal complication of coronary bypass surgery. A 49-year-old man developed mycotic pseudoaneurysm in the ascending aorta after coronary bypass in another hospital. Computed tomography showed the pseudoaneurysm originated from the previous aortic cannulation site. The defect was successfully repaired with pericardial-pledgeted sutures.