Coronary artery bypass grafting and concomitant descending aorta-to-bifemoral artery bypass via sternotomy.

INTRODUCTION: We evaluated a new approach of combined coronary and aorto-bifemoral artery bypass grafting performed through median sternotomy using the descending aorta as the inflow source. MATERIALS AND METHODS: Four patients with advanced coronary and aorto-iliac disease were operated on in the same session. Following the coronary artery bypass grafting (CABG), we performed a proximal anastomosis of a bifurcated Dacron graft to the descending aorta through the posterior pericardium. The limbs of the graft were passed through the diaphragm into the retroperitoneal space. They were then passed through tunnels in the groins, and distal anastomoses in the groins were performed. RESULTS: The postoperative course was uneventful in all four patients. In the second year, follow-up multi-slice computerised tomographies (CT) and magnetic resonance angiographies were done and all grafts were patent. DISCUSSION: We believe this technique is a reliable alternative procedure to consider in CABG patients who are not suitable candidates for standard aorto-femoral operations. It has a reasonable rate of morbidity and perfect patency.

Posterior pericardial annuloplasty in ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation (IMR) is an important risk factor in coronary artery bypass grafting (CABG) operations. The decision to perform concomitant mitral annuloplasty along with the CABG depends on the surgeon's choice. The aim of this study was to evaluate the results of posterior annuloplasty procedures with autologous pericardium performed in patients with midadvanced and advanced functional ischemic mitral regurgitation. METHODS: Study participants were 36 patients with IMR (mean age 59 +/- 10 years) who underwent posterior pericardial annuloplasty and CABG operations between 2002 and 2007. Preoperative and postoperative (mean follow-up 18 +/- 1 months) MR grade, left atrium diameter, left ventricle end systolic diameter, left ventricle end diastolic diameter, left ventricle ejection fraction, and mitral valve gradients were measured with transthoracic echocardiography. RESULTS: There was one late mortality (2, 8%) but none of the patients required reoperation for residual MR. We did not observe thromboembolism, bleeding, or infective endocarditis. The mean MR grade decreased from 3.4 +/- 0.5 to 0.5 +/- 0.6 (P < .01), left atrium diameter decreased from 45.3 +/- 5.5 mm to 43.2 +/- 3.8 mm (P < .01), left ventricle end diastolic diameter decreased from 53.2 +/- 5.6 mm to 50.9 +/- 5.5 mm (P < .01), and left ventricle end systolic diameter decreased from 39.7 +/- 5.8 mm to 34.6 +/- 6.5 mm (P < .01), whereas mean left ventricle ejection fraction increased from 37.9% +/- 6.1% to 43.7% +/- 7.3% (P < .01). In the late postoperative term, the functional capacity of the patients increased from mean New York Heart Association class 2.6 +/- 0.9 to 1.1 +/- 0.5. We did not observe any gradient in the mitral valve preoperatively in any patient, but in the follow-up, the mean gradient increased to 1.3 +/- 2.1 mmHg (P < .01). CONCLUSION: Posterior pericardial annuloplasty with CABG in the treatment of IMR provides efficient mitral repair and significant decrease in the left atrium and left ventricle diameters, and provides a significant increase in left ventricular function. These results show IMR to be as effective as the other annuloplasty techniques. IMR is performed with autologous material and therefore does not entail any risk of complications from prosthetic material and is highly cost-effective.

Revascularization of left anterior descending (LAD) artery with in situ left internal thoracic artery (LITA) and coronary-coronary free LITA grafts: 12-year patency.

BACKGROUND: We aim to present a patient with coronary-coronary bypass grafting (CCBG), left anterior descending-left anterior descending (LAD-LAD) coronary artery bypass with left internal thoracic artery (LITA), and provide the 12-year follow-up angiogram to confirm the longest reported patency. METHODS AND RESULTS: A 57-year-old man with three vessel disease where LAD had multiple lesions was operated on. LITA with pedicle was grafted in situ onto the proximal LAD, and the distal residual segment was used as a free LITA graft to bypass the distal stenosis. The postoperative course was uneventful. The patient has been recently readmitted to our clinic with atypical chest pain. In angiography, all of the bypasses, including the free LITA graft, were patent. CONCLUSIONS: We used free LITA graft to bypass the distal lesions of LAD in selected patients as a valid alternative to sequential bypass grafting. To the best of our knowledge, this is the only angiographic view of a CCBG in LAD with LITA graft confirming the long-term patency.

The effects of internal thoracic artery preparation with intact pleura on respiratory function and patients' early outcomes.

OBJECTIVE: Postoperative respiratory functions, arterial blood gases, blood loss and clinical outcome following coronary artery bypass surgery (CABG) were assessed in a prospective randomized single-blind (patient- blind) clinical study comparing two different techniques of internal thoracic artery (ITA) harvesting. METHODS: Fifty-four patients admitted for CABG were allocated into two groups according to 'random numbers' technique. In a Group 1 (n=26) ITA was prepared keeping the pleura intact and in a Group 2 (n=28) pleura was opened. Both groups were compared in terms of postoperative respiratory functions, arterial blood gases, bleeding and clinical outcomes using ANOVA for repeated measurements analysis. RESULTS: Analysis of spirometric and partial oxygen pressure data showed that postoperative reductions in forced expiratory volume (0.17+/-0.18 lt vs. 0.28+/-0.14 lt, p=0.016), forced vital capacity (0.18+/-0.19 lt vs. 0.28+/-0.13 lt, p=0.037) and arterial oxygen measurements (-0.03+/-0.22 mmHg vs. 0.15+/-0.4 mmHg, p=0.023) were less pronounced in patients of Group 1 as compared with patients of Group 2. The increase in intrapulmonary shunts (Qs/Qt ratio) after the operation was more pronounced in Group 2 patients than in Group 1 patients (p<0.01) and the mean values of Qs/Qt ratio 24 hours after the operation were higher in group 2 as compared to Group 1 patients(0.100+/-0.063 vs. 0.054+/-0.048, p=0.001). Radiological evaluation revealed that costophrenic angle obliteration after operation more often occurred in Group 2 (14/28 patients) than in Group 1 (0/26 patients) (p<0.0001). Cardiothoracic index increased significantly after operation only in group 2 patients (p=0.001). Postoperative blood loss within 24 hours was significantly lower in Group 1 compared to Group 2 (656+/-179 ml vs. 907+/-257 ml, p=0.001). There was no significant difference between groups in the ICU stay duration (p=0.186), whereas the hospital stay was significantly longer in group 2 patients than in Group 1 patients (8.8+/-2.0 days vs. 7.6+/-2.0 days, p=0.039). CONCLUSION: According to our results, preserving pleural integrity has positive effects on the respiratory functions and patients' clinical outcomes following CABG operations.

Pulmonary effects of noninvasive ventilation combined with the recruitment maneuver after cardiac surgery.

BACKGROUND: The aim of our study was to evaluate the pulmonary effects of noninvasive ventilation (NIV) with or without recruitment maneuver (RM) after open heart surgery. METHODS: One-hundred patients undergoing coronary artery bypass surgery were randomized into four groups after the operation: 1) RM with sustained inflation during mechanical ventilation postoperatively (RM group, n = 25); 2) RM combined with NIV applied for 1/2-h periods every 6 h in the first postoperative day after tracheal extubation (RM-NIV group, n = 25); 3) NIV after tracheal extubation (NIV group, n = 25); and 4) a control group consisting of patients receiving neither RM nor NIV (control group, n = 25). Pulmonary function tests, oxygenation index, and atelectasis on chest radiograph were evaluated and compared among the groups. RESULTS: RM provided higher arterial oxygen levels during mechanical ventilation and after tracheal extubation compared to other interventions. Oxygenation was better in the RM-NIV and NIV groups than in the control group (P = 0.02 and P = 0.008, respectively) at the end of the study. The postoperative atelectasis score of the control group (median: 1) was higher than those of the RM (1; P = 0.03), RM-NIV (0; P < 0.01) and NIV (0; P < 0.01) groups. Pulmonary function of the NIV groups on postoperative day 2 was better than in the other groups, whereas the tests were similar among the groups on postoperative day 7. CONCLUSIONS: NIV associated with RM provided better oxygenation both during and after the mechanical ventilation period. NIV either alone or in combination with RM provided lower atelectasis scores and better early pulmonary function tests compared to the control group, without a significant difference regarding the duration of mechanical ventilation, intensive care unit stay, and the length of hospitalization. NIV combined with RM is recommended after open heart surgery to prevent postoperative atelectasis and hypoxemia.

Inflammatory aneurysm of arcus aorta with massive hemoptysis.

A 72-year-old woman was admitted to the intensive care unit with a diagnosis of acute coronary syndrome. An aneurysm in the aortic arch was detected in the radiologic investigations. The aortic arch was replaced with a Dacron graft with the patient under total circulatory arrest. A pathology evaluation revealed an inflammatory aneurysm. To date, a few cases of inflammatory aneurysms of the aortic arch have been reported. Unlike the previously reported cases, the aneurysm in our case unexpectedly presented with massive hemoptysis.

A novel approach to surgical treatment of diseased intracavitary coronary arteries and ventriculotomy closure.

Inadvertent opening of the right ventricle may occur during dissection of an intracavitary artery. Two patients with stenotic intracavitary left anterior descending arteries were operated on. A right ventriculotomy was performed in the operation. The anastomosis was performed to this intracavitary segment of the artery. The ventriculotomy was closed with a pericardium. There were no ischemic changes or aneurysmal formation in the postoperative follow-ups. This technique may be preferable in the closure of right ventriculotomy without compromise of coronary flow or anastomosis.

Right coronary system grafts: alone or together with left system grafts--angiographic results.

PURPOSE: The aim of this study is to compare the long-term graft patency between patients who had sequential or individual right posterior descending artery (RPDA) anastomosis. MATERIALS AND METHODS: Two hundred and forty-two patients underwent coronary artery bypass grafting (CABG) between June 1994 and December 2003. They were examined retrospectively with respect to coronary angiograghic data. [Group 1] Individually right system grafts in RPDA position (n=139). [Group 2] RPDA anastomosis sequentially with left system (n=103). Patency rates for posterior descending arteries in each group were separately calculated for each vessel quality category. RESULTS: The mean interval from operation to angiography was 50.6+/-48.9 months in group 1 vs 57.5+/-39.2 months in group 2 respectively. The overall patency rate was 66.2% (92/139) in group 1 and 78.6% (81/103) in group 2 (p=0.04). When the RPDA has good run-off capacity, the patency rate was 69.1% in group 1 and 85.2% in group 2. CONCLUSION: When the RPDA has good run-off capacity, snake grafts show excellent results and right and left coronary systems could be anastomosed sequentially.

An alternative reinforced closure technique with external Kirschner wires in sternal dehiscence.

OBJECTIVE: We present an alternative closure technique that is effective in length stabilization of the dehisced sternum, technically easy, and less time consuming. METHODS: Between June 2000 and June 2003, 850 patients underwent open heart surgery in the participating clinics. In all of the patients, the sternotomies were primarily closed with No. 5 steel wires in a figure 8 manner or with single sutures. Eleven patients with sterile sternal dehiscence underwent operations with Kirschner wires. RESULTS: During the postoperative period, no complications related to the implants were observed in any of the patients in the early and late follow-ups. CONCLUSION: With this technique, the fragile sternum is easily and effectively stabilized by reinforcing with suprasternal Kirschner wires without applying complicated manipulations.

The pulmonary and hemodynamic effects of two different recruitment maneuvers after cardiac surgery.

BACKGROUND: The aim of our study was to evaluate the pulmonary and hemodynamic effects of two different recruitment maneuvers after open heart surgery. METHODS: Sixty patients undergoing coronary artery bypass surgery were randomized into three groups after operation: recruitment maneuver with continuous positive airway pressure (CPAP) (CPAP-40 group, n = 20), recruitment by positive end-expiratory pressure (PEEP) (PEEP-20 group, n = 20), and 5 cm H2O PEEP (PEEP-5 group, n = 20). In the CPAP-40 group, 40 cm H2O peak inspiratory pressure was applied for 30 s, then PEEP was reduced to 20 cm H2O and ventilation was continued with baseline variables with PEEP decreased until the best Pao2 was achieved. In the PEEP-20 group, 20 cm H2O PEEP was set for 2 min, tidal volume was adjusted to achieve a peak inspiratory airway pressure of 40 cm H2O during the maneuver, then PEEP was decreased until the best Pao2 had been achieved. In the PEEP-5 group, 5 cm H2O PEEP was applied postoperatively. RESULTS: The mean arterial blood pressure of the CPAP-40 group was lower than that of the PEEP-20 (P < 0.01) and PEEP-5 groups (P < 0.01) during the interventions. Oxygenation was higher in both recruitment groups than in the PEEP-5 group during the mechanical ventilation period. There was no significant difference among the groups beyond that period. The atelectasis score of the PEEP-5 group (1.3 +/- 0.9) on postoperative day 1 was higher than that of the CPAP-40 (0.65 +/- 0.6; P = 0.01) and PEEP-20 (0.65 +/- 0.5; P = 0.01) groups. CONCLUSIONS: The recruitment techniques with postmaneuver PEEP increased oxygenation and decreased atelectasis equally, whereas PEEP-20 provided more stable hemodynamic conditions than the CPAP maneuver.

Arch-first technique via clamshell incision: successful surgical reoperation for aortic arch dissection.

We report a case of successful reoperation for aortic arch dissection with use of the "arch-first" technique in a patient who had Marfan syndrome. Extracorporeal circulation was initiated via right subclavian artery cannulation, and the chest was entered through a clamshell incision for the best exposure. When the patient was cooled to 18 degrees C, the perfusion was stopped. After the 1st aortic arch anastomosis to a 30-mm Dacron graft, cerebral perfusion was reestablished via the right subclavian artery. The aortic repair was then completed. The cerebral ischemic time was 18 minutes, the aortic cross-clamp time was 69 minutes, and the total extracorporeal circulation time was 334 minutes. The patient was discharged from the hospital on postoperative day 10 with no neurologic impairment. The arch-first technique shortens the duration of brain ischemia. When combined with a clamshell incision, the technique is particularly helpful for reoperation of the aortic arch and thoracic aorta.

Postinfarction ventricular septal rupture: surgical intervention and risk factors influencing hospital mortality.

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention and requires urgent closure. Between 1989 and 2003 twenty consecutive patients (15 male, 5 female), underwent postinfarction ventricular septal rupture (VSR) repair. Mean age of the patients was 62.05 +/- 7.51 years. Fifteen patients were operated within 48 hours after myocardial infarction. Patch reconstruction was performed in all patients. Infarct locations were anterior in 65%, posterior in 35%. Coronary artery surgery was performed in 14 patients (70%). Hospital mortality was 30% (6 patients). Four patients were presented for surgical therapy with frank cardiogenic shock or low cardiac output syndrome. A residual shunt was detected in 4 patients and three of these patients were reoperated. One of them, who has been reoperated on the first day of the postoperative period, did not survive. The statistical analysis of the patients' records demonstrated that time period between MI and surgery, applied additional CABG procedure, the sex of the patients and the site of the rupture are significant factors influencing in-hospital mortality. Preoperative condition, age of the patients and the number of the affected coronary vessels do not have an important effect on the mortality. Postinfarction ventricular septal rupture is a fatal complication of the myocardial infarction and must be treated surgically. The time interval between septal rupture independent from the preoperative haemodynamic condition, the location of the defect and additional myocardial revascularization procedure are the factors influencing the early outcome.

Effectiveness of intraaortic balloon pumping in patients who were not able to be weaned from cardiopulmonary bypass after coronary artery bypass surgery and mortality predictors in the perioperative and early postoperative period.

OBJECTIVE: The intraaortic balloon pump (IABP) is usually the first choice of mechanical device used for perioperative cardiac failure. The aim of this retrospective study was to determine the effectiveness of intraoperative IABP use in patients who could not be weaned from cardiopulmonary bypass (CPB) and to determine the possible perioperative and early postoperative prognostic factors for mortality. METHODS: Between June 1992-December 2001 a total of 69 patients who underwent coronary artery bypass grafting and required IABP support in weaning from CPB due to cardiac pump failure were included into the study. The mean age was 61.9+/-7.5 years. The effectiveness of IABP and preoperative, operative and postoperative risk factors for mortality were evaluated retrospectively. RESULTS: Following the insertion of IABP, 59 (85.5%) patients could be weaned from CPB whereas 10 patients (14.5%) could not. In the early postoperative period, 13 (22%) patients died due to cardiac pump failure. The average in-hospital mortality rate for patients who were treated with an IABP was found as 33.3% (23 patients). Univariate analysis identified left ventricular enddiastolic pressure, ventricular performance score, urgent operation and perioperative myocardial infarction as the risk factors for early death. The minor and major IABP related complications occurred in only 8 patients. CONCLUSION: Due to the contributory effects, effectiveness and low complication rate, IABP may be used in patients who cannot be weaned from CPB.

Angiographic assessment of sequential and individual coronary artery bypass grafting.

OBJECTIVE: In trying to answer the question about the controversial use of sequential grafts, we determined the mid-term angiographic outcome of patients in whom coronary artery bypass was performed with different types of vein grafts. METHODS: A total of 1034 coronary anastomoses on 724 saphenous vein grafts (SVGs) (apart from 497 left internal mammarian artery (LIMA) anastomoses) were assessed in 509 patients in an average of 55.4 +/- 17.6 months after coronary artery bypass grafting. RESULTS: The patency rates of sequential conduits were markedly higher than those of individual ones (86.6% vs 69.6%, p = 0.0001). Also, the anastomoses on the sequential conduits had better patency rates (80.6% vs 69.6%, p = 0.0001). This difference was even more pronounced in coronary arteries of poor quality/small (< 1.5 mm) diameter (68.9% vs 51.6%) for the sequential and individual grafts, respectively (p = 0.03). Also, the patency of the entire sequential conduit was lower when most distally located anastomosis was of poor runoff (45.2%). CONCLUSIONS: The patency of a sequential vein conduit is generally superior than that of an individual one, especially for poor runoff coronary vessels, provided that the most distally located anastomosis is performed on a good coronary artery in terms of quality and diameter. Using a minimal length of SVG is another advantage. However, failure of a single sequential conduit jeopardizes all of the anastomoses along that graft segment. Besides, being technically more demanding, technical expertise in performing a sequential anastomosis is probably among the important predictors of patency.

Surgical management of left ventricular aneurysms by endoventricular pericardial patch plasty.

BACKGROUND: Early and late surgical outcomes of endocardial resection and aneursymectomy repaired with an autologous pericardial patch were studied. METHODS: We studied 125 patients who underwent endoaneurysmorrhaphy with pericardial patch during the period from June 1993 until June 2000. Preoperative, early and late postoperative results, annual postoperative echocardiography of all patients and hemodynamic controls of 35 patients within a mean follow-up of 64+/-8 months were analyzed. RESULTS: Mean NYHA improved to postoperative 2.1+/-0.5 from preoperative 2.8+/-0.4. Mean number of bypass grafts was 2.6+/-1.1. Left ventricular ejection fraction rate improved to 36.2+/-8% in one month, 39.3+/-9% in 6 months, 42.3+/-8% in one year versus preoperative 29.2+/-9% (P< or =0.05).Perioperative mortality was 6.4% (eight patients) and 11 deaths were observed in the late follow-up (9.4%). CONCLUSION: Endoaneurysmorrhaphy with pericardial patch may be an alternative option in the management of left ventricular aneurysms within acceptable surgical results.

Does microalbuminuria in diabetic patients affect the postoperative course after coronary artery bypass surgery?

OBJECTIVES: Microalbuminuria is a predictor of microvascular disease and a marker for multiorgan damage in diabetic patients. It has been proposed that in diabetic patients who would undergo coronary artery bypass surgery (CABG), microalbuminuria is associated with poor postoperative outcome, higher incidence of early and late morbidity and mortality. METHODS: Microalbuminuria was prospectively studied preoperatively in 24-h urinary collections for 257 consecutive diabetic patients in a 2-year period. One hundred and sixty-eight patients (65.4%) were defined as microalbuminuria negative (Group A), and 89 (34.6%) were microalbuminuria positive (Group B) with respect to the cut-off point 30 mg/24 h. RESULTS: The two groups did not differ with respect to preoperative and operative data, except that preoperative blood glucose levels (P=0.046), blood urea nitrogen (P=0.001), and creatinine (P=0.001) were higher and creatinine clearance was lower (P=0.025) in Group B. Postoperative serum creatinine levels on different days were higher in microalbuminuria positive patients (P=0.04). Also, positive inotropic agent usages at the time of leaving the operating room (21.3 vs. 10.1%; P=0.013) and on the 1st day in the intensive care unit (ICU; 29.2 vs. 14.9%; P=0.014), ICU stay day (2.3+/-2 vs. 2.4+/-1.6; P=0.02) and also atrial fibrillation rate (30.3 vs. 17.9%) were higher in Group B (P=0.019). Total hospital stay (7.5+/-2.9 vs. 7.2+/-1.3) was similar. The 30-day mortality was 5.6 times higher (3.4 vs. 0.6%) but statistically not significant (P=0.088) in Group B. The mean follow-up was 30.6+/-16. 2 months in total (30.9+/-16.2 in Group A and 30.1+/-16.5 in Group B). There were 12 late deaths, nine were cardiac, and no differences were detected between groups. CONCLUSIONS: Our findings suggest that postoperative period may be more problematic in diabetic patients with microalbuminuria, but microalbuminuria does not seem to have a major effect on the postoperative course in patients undergoing CABG.

Midterm angiographic results of off-pump coronary artery bypass grafting.

BACKGROUND: As off-pump coronary artery bypass grafting (OPCAB) has gained wide attention, the quality of surgical revascularization, which showed favorable initial results, is being frequently questioned. This study was undertaken to assess the midterm outcome of beating-heart coronary anastomosis. METHODS: Seventy-four of 315 patients who underwent beating-heart coronary artery bypass grafting via median sternotomy between March 1994 and December 1995 were randomly selected for angiographic assessment. RESULTS: The mean period of control angiography was 50.1 +/- 22.6 months (range, 22 to 83 months). A total of 109 (1.52 +/- 0.55) anastomosis procedures were performed in 74 patients; 38 had single-vessel disease, and 36 had double-vessel disease or disease involving more than 2 vessels. There were no perioperative returns to cardiopulmonary bypass, no major complications, and no hospital deaths. The causes of the need for occlusion included 2 (2.5%) instances of left internal mammary artery-left anterior descending artery anastomosis; 2 (2.5%) of anastomotic site stenosis in left internal mammary artery-left anterior descending artery anastomosis; 7 (19.4%) of saphenous vein graft anastomosis; and 3 (8.3%) of anastomotic site stenosis of saphenous vein graft. Statistical analysis revealed hypercholesterolemia as an independent predictor for graft occlusion (P =.014). The patency rates were not affected by endarterectomy, length of the anastomosed segment, or coronary artery structure. Event-free survival was 73.61% and myocardial infarction-free survival was 91.67%. Reintervention and reoperation rates were 24.3% (18 instances) and 1.4% (1 instance), respectively. CONCLUSIONS: Our results were encouraging for OPCAB, supporting its safety and effectiveness, patency rates and clinical outcome comparable to those of cardiopulmonary bypass, and overall benefits such as reduced hospital costs and postoperative length of stay.