Long-term results of polytetrafluoroethylene versus saphenous vein repair of degenerative carotid artery aneurysm.

OBJECTIVE: To compare the results of polytetrafluoroethylene (PTFE) and great saphenous vein (GSV) bypass after resection of a degenerative aneurysm of the carotid artery. METHODS: From January 1994 to November 2017, 37 patients (27 men) with a mean age of 58 years (range, 39-82 years) with a degenerative aneurysm of the carotid artery (median diameter, 28 mm; range, 19-42 mm), underwent resection of the aneurysm followed by a bypass with either a GSV (n = 10) or a PTFE prosthesis (n = 27). Although 31 patients were asymptomatic, 6 patients were symptomatic: transient ischemic attack (n = 4), minor stroke (n = 1), and compression of the hypoglossal nerve (n = 1). The preoperative workup included duplex ultrasound examination of the arteries to the head, and angiography or computed tomography angiography. All patients were operated under general anesthesia and six were intubated through the nose. Sixteen patients were monitored through transcutaneous oximetry. No shunt was used in this series. In 10 patients receiving a PTFE graft, the external carotid artery was implanted in the prosthesis. Mean follow-up was 16.9 ± 2 years (95% confidence interval, 14.5-19.3 years). Primary end points were the 30-day combined stroke/death rate, graft infection, late graft patency, and late stroke-free survival. Secondary end points were cranial nerve injury and length of postoperative hospital stay. RESULTS: Postoperative mortality was nil in both groups. One postoperative stroke was observed in the PTFE group, whereas none occurred in the GSV group (P = .84). No graft infection was observed in either group. At 10 years, survival in the GSV group was 80 ± 12%, and survival in the PTFE group was 76 ± 8% (log-rank [Mantel-Cox], P = .85). In the GSV group, graft patency at 7 and 10 years was 85 ± 13%. In the PTFE group B, graft patency was 100% (log-rank [Mantel-Cox], P = .12). No late stroke was observed. Two transient cranial nerve injuries were observed in the GSV group (20%) and two in the PTFE group (8%) (P = .97). Length of hospital stay was comparable in both groups (GSV group, 6 days; PTFE group, 5 days; P = .12). CONCLUSIONS: This study suggests that, after resection of a degenerative aneurysm of the carotid artery, bypass with a PTFE prosthesis gives comparable results to those obtained with the GSV. We recommend sparing the GSV and instead using a PTFE prosthesis in patients with a degenerative aneurysm of the carotid artery.

Intraoperative echocardiographic coronary artery imaging in congenital and acquired heart disease.

Transoesophageal and epicardial echocardiography are indispensible intraoperative imaging modalities to guide paediatric heart disease surgeries and influence surgical decision-making. A less well-described role of intraoperative imaging is its utility in evaluating coronary artery patency and flow. Focused two-dimensional, colour, and spectral Doppler imaging of the coronary arteries should be performed during surgeries involving coronary manipulation or re-implantation, or in cases where there is unexpected ventricular dysfunction or electrographic signs concerning for ischaemia. Intraoperative imaging allows for any anatomical issues to be detected and addressed promptly in the operating room. Imaging of the coronary arteries should identify unobstructed coronary ostia and proximal course without kinking, angulation, narrowing, or significant calibre change to suggest stenosis or extrinsic compression from neighbouring structures. The aim of this review is to highlight the usefulness of transoesophageal and epicardial echocardiography in evaluating coronary artery patency and flow, provide a how-to guide for optimal imaging, and to introduce a practical guideline to achieve best clinical practice.

Aortic valve replacement with or without myocardial revascularization in octogenarians. Can minimally invasive extracorporeal circuits improve the outcome?

OBJECTIVE: The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization. METHODS: Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010. RESULTS: A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02). CONCLUSION: MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery.

Using extra systoles and the micro-fluid challenge to predict fluid responsiveness during cardiac surgery.

Fluid responsiveness prediction is difficult during cardiac surgery. The micro-fluid challenge (micro-FC; rapid central infusion of 50 ml) and the extrasystolic method utilising post-extrasystolic preload increases may predict fluid responsiveness. Two study windows during coronary artery bypass graft surgery were defined, 1: After anaesthesia induction until surgical incision, 2: Left internal mammarian artery surgical preparation period. Each window consisted of 10-15 min observation for extrasystoles before a micro-FC was performed, after which a traditional fluid challenge (FC) was performed (5 ml/kg). Extrasystolic and micro-FC induced changes in hemodynamic variables were derived as predictors of fluid responsiveness defined as stroke volume increasing > 10% following FC. 61 patients were studied. Post-ectopic changes in pulse pressure (PP) predicted fluid responsiveness with receiver operating characteristic area (AUC) of 0.69 [CI 0.40;0.97] in the first study window and 0.64 [0.44;0.86] in the second window. Other post-ectopic predictors such as pre-ejection period (PEP) and systolic blood pressure (SBP) had similar or lower AUCs. Heart rate was 52.9 (SD ±8.4) min- 1 and 53.6 (± 8.8) min- 1 in the two study windows. Micro-FC induced changes in PEP had AUC of 0.74 [0.57;0.90] in the first window and 0.60 [0.40;0.76] in the second window. Correcting micro-FC induced changes in PEP for the micro-FC induced changes in heart rate had AUCs of 0.84 [0.70;0.97] in the first window and 0.63 [0.47;0.79] in the second window. The investigated methods revealed insufficient validity during cardiac surgery. RR interval corrected changes during a micro-FC should be investigated further. Trial registration Clinicaltrials.gov: NCT03002129.

[Microsurgical technique in coronary bypass surgery: possibilities, perspectives and limitations]. / Mikrokhirurgicheskaia tekhnika v koronarnoi khirurgii: vozmozhnosti, perspektivy i ogranicheniia.

Microsurgical approach implies a special technique of operation under operating microscope with the use of special tools and ultra-thin atraumatic sutures. This method may be used in coronary artery bypass surgery in order to improve conventional technique, its quality and outcomes. The report summarizes information about technical features, capabilities and results of microsurgical coronary artery bypass grafting. The problem of popularizing microsurgical technologies in coronary bypass surgery is also discussed.

[The results of coronary artery bypass grafting by using of surgical microscope]. / Gospital'nye rezul'taty koronarnogo shuntirovaniia s ispol'zovaniem operatsionnogo mikroskopa.

AIM: To analyze own experience of coronary artery bypass grafting (CABG) using microsurgical technique and operating microscope. MATERIAL AND METHODS: There were 100 patients with coronary artery disease who underwent CABG in the Petrovsky Russian Research Center for Surgery for the period from April 2017 to December 2018. Mean age of patients was 59.7 ± 8.9 years. Triple-vessel disease was noted in 83 (83%) patients, two-vessel - in 17 (17%) patients. Stenosis of left main coronary artery was observed in 34 (34%) patients. On-pump myocardial revascularization using microsurgical technique was performed in all patients. RESULTS: A total of 360 distal anastomoses with coronary arteries were formed in 100 patients using surgical microscope. Revascularization index was 3.6 ± 0.8, mean CPB time - 104 ± 24 min, aoric cross-clamping time - 72 ± 16 min. In-hospital mortality was absent. There were no cases of resternotomy for bleeding, infectious complications of postoperative wounds. One (1%) patient had intraoperative myocardial infarction. CONCLUSION: CABG using microsurgical technique and operating microscope may be appropriate in patients with multiple-vessel coronary lesion and small diameter of coronary arteries.

[Microsurgery of coronary arteries using an operating microscope]. / Mikrokhirurgiia koronarnykh arterii s ispol'zovaniem operatsionnogo mikroskopa.

The world experience of coronary artery bypass surgery using an operating microscope is reviewed in the article. Important role of operating microscope and microsurgical techniques for coronary anastomoses formation is shown. High optical magnification provided by operating microscope directly affects the quality of surgical technique and accuracy of coronary anastomoses suturing that affects postoperative graft patency. Thus, the use of operating microscope can affect the results of coronary artery bypass surgery, as shown in several reports.

Application of actuator-driven pulsed water jet for coronary artery bypass grafting: assessment in a swine model.

Actuator-driven pulsed water-jet (ADPJ) dissection is an emerging surgical method for dissecting tissue without heat and mechanical injury to vessels. We elucidated the mechanical properties of the piezo ADPJ and evaluated its usefulness and safety in coronary artery bypass grafting procedures. The relationship between the input voltage (10-100 V) and peak pressure of the pulsed water jet was evaluated. The tissue strengths of swine internal thoracic and coronary arteries and the surrounding tissues were measured to assure tissue-selective dissection. Internal thoracic arteries were harvested by conventional electric cautery and the water jet in four swine, and eight coronary arteries surrounded by myocardium were attempted to be exposed with the water jet. The dissected specimens were histologically evaluated. The peak pressure of the pulsed water jet was positively correlated with the input voltage (R 2 = 0.9984, P < 0.001). The breaking strengths of the target vessels (internal thoracic and coronary arteries) and the surrounding tissues were significantly different (P = 0.002 and P < 0.001, respectively). Histologic examination revealed that internal thoracic arteries were isolated with less heat damage using the pulsed water jet (P = 0.002) compared with electric cautery, and coronary arteries also were dissected without apparent histologic damage. ADPJ has the possibility of assuring tissue selectivity among the internal thoracic and coronary arteries. The results also indicated that the use of ADPJ may enhance safe procedures to harvest grafts during coronary artery bypass grafting.

String Music: Creating Coronary Artery and other Vascular Anastomoses.

The initial version of this treatise was written as I (Curt Tribble) was learning to do coronary anastomoses over 30 years ago, and I worried that I was not being taught very well how to go about doing them. It seemed to me that my teachers were channeling Dr. Alain Carpentier, who often answered questions about his mitral valve repair techniques by saying, "Oh, you just know." These frustrations were compounded by the fact that the best cardiovascular techniques books, including even those texts dedicated to coronary artery bypass techniques, did not describe these anastomotic techniques in detail, which remains the case to the present day [Kaiser 2007; Copeland 1986].

Dynamic Three-Dimensional Geometry of the Aortic Valve Apparatus-A Feasibility Study.

OBJECTIVE: To provide (1) an overview of the aortic valve (AV) apparatus anatomy and nomenclature, and (2) data regarding the normal AV apparatus geometry and dynamism during the cardiac cycle obtained from three-dimensional transesophageal echocardiography (3D TEE). DESIGN: Retrospective feasibility study. SETTING: A single-center university teaching hospital. PARTICIPANTS: The study was performed on data of 10 patients with a nonregurgitant, nonstenotic aortic valve undergoing cardiac surgery. INTERVENTIONS: Intraoperative 3D TEE was performed on all the participants using the Siemens ACUSON SC2000 ultrasound system and Z6Ms transducer (Siemens Medical Systems, Mountainview, CA). MEASUREMENTS AND MAIN RESULTS: Dynamic offline analyses were performed with Siemens eSie valve analytical software in a semiautomated fashion. Forty-five parameters were exported of which 13 were selected and analyzed. The cardiac cycle was divided into 4 quartiles to account for frame-rate variations. The annulus, sinus of Valsalva (SoV) and sinotubular junction (STJ) areas, diameter, perimeter and height, aortic leaflet height, leaflet coaptation height, and aortic valve-mitral valve angle changed significantly during the cardiac cycle (p < 0.001). STJ expanded more than both the annulus and the SoV (p < 0.001). The maximum aortic valve leaflet height change was greater in the left and right versus noncoronary leaflet (p < 0.001). CONCLUSIONS: The semiautomated AV apparatus dynamic assessment using eSie valve software is a clinically feasible technique and can be performed readily in the operating room. It has the potential to significantly impact intraoperative decision-making in cases suitable for AV repair. The AV apparatus is a dynamic structure and demonstrates significant changes during the cardiac cycle.

[Individual learning curves for microsurgical myocardial revascularization]. / Individual'nye krivye obucheniia mikrokhirurgicheskoi revaskuliarizatsii miokarda (s kommentariem).

AIM: To create individual learning curves for microsurgical myocardial revascularization. MATERIAL AND METHODS: It was analyzed duration of the individual stages of the first 100 CABG procedures which were performed using microsurgical technique and surgical microscope. Graphs reflecting correlation between duration of the individual surgical stages and their number were framed. RESULTS: Improvement in distal anastomosis time, aortic cross-clamping time, cardiopulmonary bypass time and duration of surgery was observed with increased surgeon's experience. CONCLUSION: Individual learning curves objectively characterize the learning process of microsurgical myocardial revascularization, allow to estimate the time need for improvement of cardiac surgeons' qualification and demonstrate dates for achieving average surgical quality during learning the technique.

Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution.

BACKGROUND: Performing minimally invasive direct coronary artery bypass (MIDCAB) grafting via small chest incisions on a beating heart is challenging. We report our experiences of MIDCAB with the utilization of both an improved rib spreader to harvest the left internal mammary artery (LIMA) and a new-shaped cardiac stabilizer to facilitate LIMA-left anterior descending (LAD) coronary anastomosis. METHODS: Between May 2012 and June 2104, a total of 200 patients who were consecutively operated on in this period were enrolled in this study. Data reported included demographic information, preoperative clinical and cardiac status, LIMA harvest time, postoperative in-hospital outcomes, and 30-day mortality. RESULTS: The average LIMA harvest time was 43 min. The mean age was 62.59 ± 10.19 years, and 45 of the 200 were females. The 30-day mortality was 0.5% (one patient) due to perioperative myocardial infarction. Duration of mechanical ventilation and length of stay in intensive care unit was 9.27 ± 7.65 and 24.27 ± 17.85 h, respectively. The unit of packed RBC transfusion was 0.79 ± 1.58. Postoperative atrial fibrillation was observed in 14 (7%) patients. There was no postoperative stroke, renal failure, or incision complication. CONCLUSION: Performing MIDCAB with the improved retractor and stabilizer utilized in this study showed favorable outcomes in terms of harvesting the LIMA, postoperative morbidities, and 30-day mortality.

A systematic review of the safety and efficacy of distal coronary artery anastomotic devices in MIDCAB and TECAB surgery.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) techniques may improve recovery and reduce hospital stay following coronary artery bypass surgery (CABG). However, working in a limited space with indirect visualisation would greatly benefit from a simple, high-quality and reproducible automated distal anastomotic method. Several devices have been developed; however, their uptake has been limited due to uncertainty around their impact on patient outcomes. METHODS: A systematic review of the literature identified six studies, incorporating 139 subjects undergoing MIDCAB or TECAB surgery using a distal anastomotic device. RESULTS: The overall 30-day mortality was 0.7% (1/137). No cardiac specific mortality was observed. For each outcome of perioperative myocardial infarction (MI), postoperative stroke and haemorrhage, only a single event was observed for each (n=1/136, 1/138 and 1/136, respectively). The overall device failure rates were low, with the use of additional sutures only reported in a single case with the Magnetic Vascular Port (MVP) device. Anastomotic time ranged from a mean of 3.32 minutes with the MVP device to 20 minutes with the C-Port device. CONCLUSIONS: These results demonstrate the overall acceptable early outcomes of distal anastomotic devices for use in minimally invasive coronary bypass surgery. Future research should focus on designing adequately powered, comparative, randomised trials, focusing on major adverse cardiac and cerebrovascular events (MACCE) outcomes in both the short and long-term, with clear case-by-case reasons for device failure and a comparison of anastomotic times. In this way, we may determine whether such devices will facilitate the minimal access and robotic coronary procedures of the future.

A New Suturing Device for Small Arteries.

Endoscope-assisted surgery and robot-assisted surgery are not common in cardiac surgery, particularly coronary artery bypass grafting, because of the complex nature of the procedures. We developed a new suturing device that allows for easy performance of such cardiac surgeries in comparison with conventional suturing methods. A total of 63 rabbits were used in this study. The right carotid artery was bypassed using the same side of the jugular vein under endoscopic guidance. Of these, 48 rabbits were operated on using the new devices and 15 rabbits were operated on using conventional polypropylene sutures. The proximal suturing time was 16.6 ± 5.3 minutes in the group that underwent surgery using the new device (group D) and 22.8 ± 7.6 minutes in the control group (group C; P < 0.05). The distal suture time was 16.3 ± 4.2 minutes in group D and 22.8 ± 6.0 minutes in group C (P < 0.05). The operation time was 113.0 ± 15.8 minutes in group D and 136.7 ± 20.6 minutes in group C (P < 0.05). Graft flow was 19.9 ± 12.8 mL/minute in group D and 12.1 ± 11.3 mL/minute in group C (P < 0.05). Thus, the operation time and the suture time differed significantly between the groups. This device provides advantages in endoscopic surgery compared to the conventional suture method.

Acute Stent Fracture During Balloon Post Dilation of an Everolimus Eluting Stent.

Coronary artery stent fracture is a well described complication during percutaneous intervention, with rates ranging from 0.84 to 8.4 percent in first generation drug eluting stents. Complications of stent fractures usually present with symptoms of acute coronary syndrome or progressive angina days, months to years after initial implantation. We present a case of an acute stent fracture during post balloon dilation of an everolimus eluting stent at a critical stenosis junction of a saphenous vein graft to the first diagonal of the left anterior descending artery. A shorter oversized drug eluting stent was placed to cover the stent fracture with good angiographic results. To our knowledge, this is the first incidence in literature of an acute stent fracture in a saphenous vein graft.

[Minimally Invasive Coronary Artery Bypass Grafting Using Proximal Anastomoses Device;Report of a Case].

A 68-years-old male with diabetes mellitius (HbA1c 6.5%) was referred for coronary artery bypass grafting(CABG). Preoperative coronary angiography (CAG) signed 3-vessels coronary disease[#2 75 %,#4 posterior descending (PD) 75%,#6 90%,#14 90%]. Minimally invasive coronary artery grafting (MICS CABG) was selected because of faster postoperative recovery than off-pump CABG via a 10 cm left 5th thoracotomy approach. In situ bilateral internal thoracic artery(BITA) and saphenous vein (SVG) was harvested by special manner using long type Harmonic. Bypass graft design was in situ right internal thoracic artery-LAD, in situ left internal thoracic artery-left circumtlex#14, and aorta-SVG-#4PD-#4atrio-ventricular. BITA, the ascending aorta for proximal anastomoses, and all coronary targets were directly accessed with off-pump technique. Heartstring III Proximal Seal System was used to anastomose SVG to the ascending aorta. There were no major postoperative complications. Postoperative CAG revealed all grafts patent and postoperative hospital stay was 14 days. This case was the 1st usage of Heartstring III Proximal Seal System in our clinic. We believe that the usage of Heartstring III Proximal Seal System in MICS CABG is realistically possible, and providing good quality;however, further research will be needed.

Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution.

BACKGROUND: Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan. METHODS: In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively. RESULTS: The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization. CONCLUSION: Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

Stenting a moving target. Neurological and hemodynamic recovery after 80 minutes of CPR using an automated chest compression device to facilitate percutaneous coronary intervention.

Despite significant advances in the science of resuscitation, survival to discharge after an in-hospital cardiac arrest in the catheterization laboratory remains poor. Clinicians face the challenges of performing CPR during procedures to address the cause of the arrest and the limitations of prolonged manual CPR. In this article we describe the first case of a patient presenting in cardiogenic shock caused by acute coronary syndrome secondary to bypass graft failure who developed cardiac arrest and survived 80 minutes of resuscitation in the catheterization lab, allowing for revascularization of a vein graft. The patient experienced complete neurological and hemodynamic recovery. This case demonstrates the importance of prompt high-quality, uninterrupted CPR using an automated chest compression device to facilitate early emergent revascularization of a vein graft.

Use of polycaprolactone grafts for small-diameter blood vessels.

Current trends are toward actively developing approaches of tissue engineering, aimed at creating vascular grafts of small diameter. This is due to the existing in cardiovascular surgery demand for prostheses to be used in coronary artery bypass grafting. The present work was undertaken in order to assess possibilities of using smalldiameter vascular grafts made of biodegradable polymer polycaprolactone by means of electrospinning. The authors studied physico-mechanical properties and structure of polycaprolactone grafts, as well as their thromboresistance and patency after implantation into the vascular bed of rats. The obtained results demonstrated optimal physicomechanical properties of the vascular grafts, their biocompatibility, endothelialisation of the internal surface, and infiltration of the graft's wall by cells with the formation of new tissue, accompanied and followed by the development of an extensive intimal layer in the zones of the anastomoses. Hence, the study showed possibilities of using polycaprolactone grafts as vascular prostheses, however requiring their further modification which would promote and contribute to a decrease in hyperplasia of connective tissue in the graft's lumen.

Robot-assisted minimally invasive direct coronary artery bypass grafting. ThoraCAB.

BACKGROUND: The aim of this study was to assess the outcome of robot-assisted minimally invasive direct coronary artery bypass grafting (MIDCAB), which is also termed "ThoraCAB". METHODS AND RESULTS: From 2005 to 2013, 35 consecutive patients underwent MIDCAB via a small thoracotomy on a beating heart. Before performing MIDCAB, the internal thoracic arteries (ITAs) were endoscopically harvested through 3 ports using the da Vinci Surgical System in a completely skeletonized fashion. Distal anastomosis was hand-sewn using a vacuum stabilizer, and a coronary artery active perfusion system was used to prevent myocardial ischemia during anastomosis. Successful robot-assisted ITA harvesting was achieved in all patients. There was an average of 1.7±0.8 grafts (range, 1-3 grafts) per patient. No patient needed mechanical ventilation for more than 24h. There were no deaths, strokes or myocardial infarctions, and none of the patients required conversion to median sternotomy. CONCLUSIONS: Robot-assisted ITA harvesting is safe and feasible. ThoraCAB is a relatively simple procedure and allows multivessel bypass grafting after a small thoracotomy. Therefore, it is expected that ThoraCAB will become the standard procedure for minimally invasive coronary revascularization and will be used in totally endoscopic CABG in the future.