Saphenous vein to the right coronary system from the right thoracic artery or the aorta. Long-term propensity-matched results of 2 groups.

OBJECTIVES: Since 2000, we anastomosed the saphenous vein graft to the right coronary artery system using the stump of the right internal thoracic artery as inflow. The long-term results of patients where the right coronary artery was grafted with the right internal thoracic artery or the ascending aorta as saphenous vein inflow has not been reported. METHODS: From 2000 to 2018, 699 consecutive patients had right internal thoracic artery elongated with saphenous vein (I-graft group, n = 358, 51.2%) or saphenous vein from the aorta (Ao-graft group, n = 341, 48.8%) on right coronary artery system. Inclusion criteria were age ≤75 years, bilateral internal thoracic arteries as a Y graft on the left system (three-vessel disease, n = 603, 86.3%) or as a left internal thoracic artery on left anterior descending and right internal thoracic artery elongated with saphenous vein on the right coronary artery system (two-vessel disease, n = 96, 13.7%), only 1 saphenous vein per patient. Propensity-matching identified 272 patients per group. One-hundred and twenty-two patients underwent coronary computed tomographic angiography to asses grafts patency after a median follow-up of 88 (65-93) months. RESULTS: In the paired samples, there was no difference in the early outcome. Ten-year survival and freedom from death, non-fatal acute myocardial infarction and repeat revascularization were higher in I-graft group: 90.6 [standard error (SE): 2.0] vs 78.2 (SE: 5.3), P = 0.0266, and 85.2 (SE: 2.4) vs 69.9 (SE: 5.3), P = 0.0179. Saphenous vein graft, at a long-time follow-up, showed a higher patency rate (81.6% (SE: 7.0) vs 50.7% (SE: 7.9), P < 0.0001) and a smaller internal lumen diameter (2.7, standard deviation: 0.4 vs 3.4, standard deviation: 0.6 mm, P < 0.0001) when right internal thoracic artery was the inflow. CONCLUSIONS: Grafting the right coronary artery with saphenous vein may entail higher patency rate and better outcome when the inflow is the right internal thoracic artery than when is the ascending aorta. Prospective randomized data are needed to test this hypothesis.

The π-Circuit Technique in Coronary Surgery: Analysis of 1359 Consecutive Cases.

Coronary artery bypass surgery still has its unique role in the treatment of coronary artery disease. It faces, however, the continuous challenge of becoming even less invasive and more effective as cases become more complex. We here present the results of 1359 cases treated with the π-circuit technique which consists of an off-pump total myocardial revascularization using composite arterial grafts. The results demonstrate that it is a safe technique providing low mortality, stroke, renal failure, wound infection, and other complication rates. We suggest the application of this technique, as well as of other similar techniques regarding similar principles, especially in high-risk patients.

Anaortic coronary surgery using the Π-circuit is associated with a low incidence of perioperative neurological complications.

OBJECTIVES: Our goal was to compare the observed and the expected rates of postoperative cerebrovascular accidents (CVA) in a large cohort of consecutive patients undergoing off-pump coronary artery bypass grafting (CABG) using the ∏-circuit as a no-touch technique. METHODS: From January 2001 to May 2016, 3081 patients were consecutively submitted to an off-pump CABG operation using the ∏-circuit. A CVA was defined as a neurological deficit, lasting less (transient ischaemic attack) or more (stroke) than 24 h, diagnosed by a neurologist and confirmed by a computed tomography or magnetic resonance imaging scan of the brain. The primary end point was to compare the observed and the expected rates of CVAs; the latter was obtained using the Society of Thoracic Surgeons' calculator. The secondary end point was to compare the observed and the expected mortality rates using the Society of Thoracic Surgeons' calculator and the prevalence of postoperative complications. Moreover, we identified some subgroups at higher risk. RESULTS: The postoperative rate of CVAs was 0.5% (14 cases): 2 (0.1%) were transient ischaemic attacks and 12 (0.4%) were strokes. The mean expected CVA rate (1.6%) was significantly higher than the observed rate (P < 0.001). None of patients who experienced postoperative CVAs died. The observed mortality was 1.3% (40 patients) vs the expected mortality (2.6%), which was significantly higher (P < 0.001). Multivariable analysis identified age >70 years old, diabetes, extracardiac vasculopathy and chronic renal failure as risk factors for postoperative CVAs. However, in all the subgroups of risk, except for those with chronic renal failure, the use of the ∏-circuit was associated with a low rate of CVAs. CONCLUSIONS: The ∏-circuit should be included as a possible choice among no-touch techniques. The observed rate of CVAs of 75% is lower than the expected rate.

Impact of obesity on outcome of patients undergoing off-pump coronary artery bypass grafting using aorta no-touch technique.

We prospectively examined 1359 adult patients undergoing isolated coronary revascularization with the Pi-circuit technique, consisting of beating heart, aorta no-touch, use of composite grafts, and off-pump arterial revascularization. Patients were divided into two groups based on body weight; Group A consisting of 295 (21.7%) obese patients [body mass index (BMI) > or =30 kg/m(2)] and Group B of 1064 (79.3%) non-obese patients (BMI <30 kg/m(2)). Advanced age and emergency surgery favored the non-obese group [63.0+/-10.4 vs. 65.3+/-9.6 years (P<0.0005) and 10.2% vs. 17.1% (P=0.004), with an increase in the number of octogenarians among them (1.7% Group A vs. 5.4% in Group B, P=0.11)]. The use of double internal mammary arteries (90.5% in Group A vs. 86.9% in Group B, P=0.109), the mean number of distal anastomoses (2.8+/-0.9 in Group A vs. 2.7+/-0.9 in Group B, P=0.5) and the number of sequential anastomoses performed (28.1% in Group A vs. 31% in Group B, P=0.3) were similar. No difference in morbidity rates was detected. All cause in-hospital mortality was comparable. Survival was similar in both groups also. Obesity is not a risk factor for morbidity and mortality in this group of patients.

Female risk using OPCAB, pi-circuit, and aorta no-touch coronary revascularization.

BACKGROUND: In this study, we evaluated female sex as a risk factor in the off-pump coronary artery bypass (OPCAB), aorta no-touch technique. MATERIALS AND METHODS: From February 2001 to November 2005, 1359 patients in our institution underwent isolated coronary revascularization with the pi-circuit technique, which consists of (1) beating heart surgery, (2) OPCAB, (3) no touching of the aorta, (4) use of composite grafts, and (5) arterial revascularization. There were 1159 men (group A) and 200 women (group B). Both groups were compared with respect to preoperative risk factors, intraoperative parameters, and postoperative morbidity and mortality. Follow-up lasted from 4 to 60 months. Data were analyzed with the chi(2) test, the Fisher exact test, the Kaplan-Meier method, and the Cox model of regression analysis. RESULTS: Female patients were older (P < .0005) and had higher prevalences of obesity (P < .0005), arterial hypertension (P < .0005), and diabetes (P < .0005). Emergency operations were also more frequent in this group (P < .027). There was no difference between the groups in the preoperative use of an intra-aortic balloon pump (IABP). The 2 groups were not significantly different with respect to 30-day mortality (1.1% versus 4%) or 7-day mortality (0.3% versus 0%). The 2 groups had comparable rates of IABP use postoperatively. Cognitive disturbances and strokes were rarely encountered (0.6% in men and 0.2% in women). In the early postoperative phase, women had more pulmonary complications (P < .014), and survival seemed to favor the male group during the follow-up period (P < .001). Further analysis with the Cox regression model with exclusion of confounding preoperative morbidity factors (more prevalent in group B) showed that the 2 groups had similar survival rates. As a group, women were 1.06 times more likely to die from a cardiac cause than men (P < .897). CONCLUSIONS: The use of the pi-circuit, aorta no-touch technique is equally effective and safe for both sexes. Women are more prone to pulmonary complications in the early postoperative phase. The apparent difference in survival favoring men can be attributed to the higher prevalence of preoperative risk factors in women. In general, we consider the off-pump, aorta no-touch technique an effective method for lowering morbidity and mortality in the relatively high-risk female patient group.

Aorta no-touch off-pump coronary artery revascularization in octogenarians: 5 years' experience.

BACKGROUND: Approximately 18% of octogenarians have ischemic heart disease. Increasingly, they are being referred for coronary artery revascularization by surgical and/or percutaneous procedures. These strategies have been questioned, however, because of reports of poor outcomes in the elderly. In this study, we aimed to determine the impact of age on morbidity and mortality in patients undergoing off-pump coronary artery bypass (OPCAB) with the pi-circuit procedure during 5 years of follow-up. MATERIALS AND METHODS: From February 2001 to November 2005, 1359 patients underwent isolated coronary revascularization with the pi-circuit technique, which consists of (1) beating heart surgery, (2) OPCAB, (3) no touching of the aorta, (4) use of composite grafts, and (5) arterial revascularization. Sixty-two patients were > or = 80 years of age (group A), and 1297 were <80 years old (group B). Both groups were compared with respect to preoperative risk factors, intraoperative parameters, and postoperative morbidity and mortality. Follow-up lasted from 4 to 60 months. Data were analyzed with the chi(2) test, the Fisher exact test, the Kaplan-Meier method, and the Cox model of regression analysis. RESULTS: Females predominated among the octogenarians (P < .0005). Octogenarians more frequently underwent emergent operations (P < .031) and had worse ejection fractions (P < .026). Obesity was also less prevalent among these patients (P < .007). There were no differences between the groups in the preoperative and postoperative use of an intraaortic balloon pump. Octogenarians had lower cholesterol levels (P < .0005) and had fewer distal anastomoses (2.24 + or - 0.0.76 versus 2.77 + or - 0.92, P < .0005). The 2 groups were not significantly different with respect to 30-day mortality (3.2% versus 1.5%) and 7-day mortality (1.6% versus 0.2%). Differences were noted in the incidences of pulmonary complications (12.9% versus 5.6%, P < .027), atrial fibrillation (41.9% versus 19%, P < .0005), and cognitive disturbances (6.5% versus 0.3%, P < .0005). During follow-up, survival seemed to favor the younger group (P < .001). Nevertheless, further analysis of the data with the Cox regression model to exclude confounding risk factors, revealed the survival rates of the 2 groups to be similar. CONCLUSIONS: Use of the pi-circuit technique is very effective for octogenarians. Although these older patients have a higher incidence of early postoperative morbidity, overall survival is not affected.

Predictors of prolonged mechanical ventilation following aorta no-touch off-pump coronary artery bypass surgery.

OBJECTIVE: To identify parameters associated with prolonged mechanical ventilation (PMV) (>48 h) after off-pump coronary artery bypass (OPCAB) in our patient population. MATERIALS AND METHODS: From February 2001 to November 2005, we operated on 1359 patients for isolated coronary revascularization with the pi-circuit technique, consisting of: (1) beating heart, (2) OPCAB, (3) aorta no-touch, (4) use of composite grafts, and (5) arterial revascularization. RESULTS: From the total number of our patients, 1320 patients had been extubated within 48 h postoperatively (Group A) and 39 patients needed PMV (Group B). In our study we have found that PMV were associated with advanced age (64.74+/-9.85 Group A vs 68.43+/-10.03 Group B, p<0.02) as well as higher incidence with octogenarians (4.4% Group A vs 10.2% Group B, p=0.09). Patients with preoperative history of transient ischemic attacks (TIAs) or stroke were more likely to belong to Group B (1.5% Group A vs 7.7% Group B, p<0.02; 2.8% Group A vs 10.3% Group B, p<0.02, respectively). Preoperative intra-aortic balloon pump (IABP) insertion was associated with PMV (1.6% Group A vs 15.4% Group B, p<0.0005). Unexpectedly, neither COPD nor obesity was associated with PMV (4.9% Group A vs 7.7% Group B, p=NS, 21.7% Group A vs 23.1% Group B, p=NS, respectively). CONCLUSION: In this study, PMV following aorta no-touch OPCAB was related to preoperative variables: age, octogenarians, preoperative IABP, TIA, and stroke. There was no relation between PMV and any of the operative data.

External reshaping of the left ventricle in off-pump surgery.

BACKGROUND: : Dyskinetic areas of the lateral and inferior left ventricular (LV) wall are frequently encountered in patients with coronary artery disease. In clinical practice, all of the techniques described for the restoration of shape and function of the LV require cardiopulmonary bypass. A new technique of LV external reshaping that aims to obtain a near-normal ventricular conical shape is described. This technique is performed during an off-pump coronary artery bypass graft (CABG) operation. It is used mainly on the inferior and lateral walls of the ventricle, but also on the anterolateral wall when warranted. This technique can be considered an alternative to classic aneurysmectomy in high-risk cases. METHODS: : All patients underwent total arterial revascularization without aortic manipulation. Intraoperative transesophageal echocardiography was used in all cases to define the dilated akinetic/dyskinetic area. This area was effectively plicated using interrupted mattress sutures reinforced with Teflon felt or pericardial strips. This technique allows near normalization of the geometry of the ventricle and LV end-diastolic volume reduction. In cases of preexisting mitral regurgitation (MR), a reduction of the MR was observed after lateral wall restoration. From September 2002 to April 2005, the external reshaping technique was applied on 56 cases among 949 off-pump CABG cases (5.9%). A detailed transthoracic echocardiogram was obtained preoperatively. The mean ejection fraction of all enrolled patients was 31.2 ± 7%. The location of the plication was: lateral wall in 22, inferior wall in 16, and anterolateral wall in 18. The average number of coronary anastomoses was 2.6. Twelve patients were found to have 2-3+ MR. All patients were followed up during a period of 35 months. RESULTS: : One patient died due to severe right ventricular dysfunction. Seven patients developed atrial fibrillation, and one had ventricular tachycardia. During the follow-up period, we observed a reduction of left ventricular end-diastolic diameter and a parallel augmentation of ejection fraction (mean 42.2 ± 4%). The ventricular cavity's architecture was normalized. Among the 12 patients with MR, an improvement of regurgitation was noted in 10 (from 2-3+ to 1-2+). One patient died during the follow-up period, and 1 patient required reoperation due to persistent severe MR. CONCLUSIONS: : The external reshaping of the LV during beating heart surgery is technically feasible, has promising results, and can be performed without major complications.