Right-ventricular global longitudinal strain may predict neo-aortic arch obstruction after Norwood/Sano procedure in children with hypoplastic left heart syndrome.

Neo-aortic arch obstruction (NAAO) is a common complication following the Norwood/Sano procedure (NP) for hypoplastic left heart syndrome (HLHS) and is associated with increased morbidity and mortality. However, there is currently no objective method for predicting which patients will develop NAAO. This study was designed to test the hypothesis that hemodynamic changes from development of NAAO after NP in patients with HLHS will lead to changes in myocardial dynamics that could be detected before clinical symptoms develop with strain analysis using velocity vector imaging. Patients with HLHS who had at least one cardiac catheterization after NP were identified retrospectively. Strain analysis was performed on all echocardiograms preceding the first catheterization and any subsequent catheterization performed for intervention on NAAO. Twelve patients developed NAAO and 30 patients never developed NAAO. Right ventricular strain was worse in the group that developed NAAO (-6.2 vs. -8.6 %, p = 0.040) at a median of 59 days prior to diagnosis of NAAO. Those patients that developed NAAO following NP were significantly younger at the time of first catheterization than those that did not develop NAAO (92 ± 50 vs. 140 ± 36 days, p = 0.001). This study demonstrates that right ventricular GLS is abnormal in HLHS patients following NP and worsening right ventricular strain may be predictive of the future development of NAAO.

An angiographic predictor of pulmonary artery stenosis after the Norwood-Sano operation for hypoplastic left heart syndrome.

The objective of this study was to determine angiographic predictors of future pulmonary artery stenosis (PS) in patients with hypoplastic left heart syndrome (HLHS) at the time of pre-stage 2 cardiac catheterization (PS2C). The Sano modification of the Norwood operation (NSO) for HLHS includes placement of a right ventricle-to-pulmonary artery (RV-PA) conduit. Branch PS is a recognized complication. Data from patients with HLHS who underwent NSO from 2005 to 2009 and who underwent PS2C were reviewed retrospectively. Nakata and McGoon indices were calculated in the traditional fashion, and modified Nakata and McGoon indices were calculated using the narrowest branch PA diameters. Thirty-three patients underwent NSO and 28 patients underwent PS2C. Mean follow-up was 35.8 ± 7.5 months. Ten (36 %) patients had significant left branch PS, with two requiring balloon angioplasty and eight requiring stent placement, a median of 15.2 months after PS2C (interquartile range 1.2, 32.8). The modified Nakata index was predictive of future intervention for left PS (receiver operating characteristic curve area under the curve 0.811), with a cut-off of 135 mm(2)/m(2) and a sensitivity of 100 % and specificity of 72.2 %. A modified Nakata index <135 mm(2)/m(2) at PS2C predicts future need for intervention on left-branch PS in patients with HLHS after the NSO. Surgical pulmonary arterioplasty at the time of stage 2 surgical palliation may obviate the need for future interventions.

Elective hypothermic circulatory arrest to address aortic pathology is safe for the elderly.

BACKGROUND: Due to assumptions of excessive risk, hypothermic circulatory arrest (HCA) has been considered prohibitive in elderly patients. However, as more elderly patients are referred for assessment of difficult aortic valve, ascending aorta, and aortic arch pathology, the risk of HCA in these patients needs to be addressed. We hypothesized that the use of HCA would not increase mortality or complications in elderly patients compared to younger counterparts. METHODS: We retrospectively reviewed the charts of adult patients who underwent elective HCA between January 1995 and June 2007. Of 147 procedures, 45 patients were >or=75 years old. These patients were compared to their younger counterparts in terms of comorbidities, operations, and complications. RESULTS: Comparing patients >or=75 years old to their younger counterparts revealed no significant differences in outcomes including nearly identical rates of confusion (>or=75 15% vs <75 9%, p > 0.5) and stroke (>or=75 11% vs <75 7%, p > 0.2). There was also no difference in 30-day mortality (>or=75 7% vs <75 7%, p = 0.9). Lengths of hospital stays and intensive care unit stays were longer in the older patients, but this was not statistically significant. CONCLUSION: In this study, elderly patients faired well with HCA compared to younger patients. These data suggest that the use of HCA is safe in selected elderly patients. Elderly patients should be considered for indicated procedures of the aortic valve, ascending aorta, and aortic arch regardless of age.

Cardiovascular magnetic resonance of pulmonary artery growth and ventricular function after Norwood procedure with Sano modification.

For hypoplastic left heart syndrome (HLHS), there have been concerns regarding pulmonary artery growth and ventricular dysfunction after first stage surgery consisting of the Norwood procedure modified with a right ventricle-to-pulmonary artery conduit. We report our experience using cardiovascular magnetic resonance (CMR) to determine and follow pulmonary arterial growth and ventricular function in this cohort. Following first stage palliation, serial CMR was performed at 1 and 10 weeks post-operatively, followed by cardiac catheterization at 4-6 months. Thirty-four of 47 consecutive patients with HLHS (or its variations) underwent first stage palliation. Serial CMR was performed in 20 patients. Between studies, ejection fraction decreased (58 +/- 9% vs. 50 +/- 5%, p < 0.05). Pulmonary artery growth occurred on the left (6 +/- 1 mm vs. 4 +/- 1 mm at baseline, p < 0.05) but not significantly in the right. This trend continued to cardiac catheterization 4-6 months post surgery, with the left pulmonary artery of greater size than the right (8.8 +/- 2.2 mm vs. 6.7 +/- 1.9 mm, p < 0.05). By CMR, 5 had pulmonary artery stenoses initially, and at 2 months, 9 had stenoses. Three of the 9 underwent percutaneous intervention prior to the second stage procedure. In this cohort, reasonable growth of pulmonary arteries occurred following first stage palliation with this modification, although that growth was preferential to the left. Serial studies demonstrate worsening of ventricular function for the cohort. CMR was instrumental for detecting pulmonary artery stenosis and right ventricular dysfunction.

Subfascial endoscopic perforating vein surgery (SEPS) for the treatment of venous ulcers.

Lower extremity ulcerations that result from venous hypertension are a significant cause of disability in Western nations. Venous ulcers, highly related to lower extremity venous valvular incompetence and post-thrombotic syndrome, demonstrate a protracted course of healing with a high recurrence rate when managed conservatively. Effective treatment includes correcting the elevated lower extremity venous pressure using non-invasive (compression therapy) or invasive modalities (removal or correction of incompetent venous segments, most commonly the greater saphenous vein). Minimally invasive subfascial endoscopic perforating vein surgery, performed on an outpatient basis, allows ligation of incompetent Cockett perforating veins. Venous ulcer healing rates of 88% and infrequent wound complications have been reported using this technique. Using 5-mm cameras and trocars that are available for other endoscopic surgeries could further improve this technique; creating ports smaller than the traditional 15-mm incisions would subsequently reduce tissue disruption. In addition, the etiology of recurrent ulceration and the failure of the primary ulcer to heal are not completely understood. If these poor outcomes can be further defined, even higher rates of wound healing may be attained using this procedure. Significant efforts have been devoted to elucidating the exact mechanism of skin breakdown from venous hypertension but the pathophysiology of this process is still not understood.

Head and neck vessel size by angiography predicts neo-aortic arch obstruction after Norwood/Sano operation for hypoplastic left heart syndrome.

OBJECTIVES: To identify and predict neo-aortic arch obstruction (NAAO) in children after Norwood/Sano operation (NO) for hypoplastic left heart syndrome (HLHS). BACKGROUND: NAAO is associated with morbidity and mortality after NO for HLHS and no objective measure has predicted the initial occurrence of NAAO. Computational flow models of aortic coarctation demonstrate increased wall shear stress (WSS) in vessels proximal to the coarctation segment, which we believe also occurs with NAAO. These vessels respond by increasing their luminal diameter to maintain normal WSS. We hypothesized that the relative increase in diameters of head and neck vessels to the isthmus, as measured by angiography, would identify hemodynamically significant NAAO and predict future NAAO. METHODS: Retrospective review of patients with HLHS and at least one catheterization with aortic angiography after NO. Diameters of head and neck vessels were totaled and divided by the isthmus diameter to give a head and neck index (HNI), which was compared to coarctation index (CI) for identifying and predicting future NAAO. RESULTS: Forty-four patients were identified, 17 with and 27 without NAAO. Receiver operator characteristic analysis using a value for CI ≤0.5 showed a sensitivity of 47% and specificity of 89%. For HNI, a value >2.65 gave a sensitivity of 77% and specificity of 93%. Three patients who developed NAAO after their initial catheterization had CI >0.5, but abnormally high HNI >2.65. CONCLUSIONS: HNI is a more robust indicator of hemodynamically significant NAAO than CI and may predict its future occurrence after NO for HLHS.

Short and long-term outcomes for bidirectional glenn procedure performed with and without cardiopulmonary bypass.

BACKGROUND: The bidirectional Glenn (BDG) procedure is most commonly used as staged palliation for complex cyanotic congenital heart defects. The benefits of a BDG procedure without the use of cardiopulmonary bypass (CPB) remain mixed within reported series. The purpose of this study was to compare short- and long-term outcomes for performance of a BDG procedure with and without the use of CPB. METHODS: From 2001 to 2010, 106 patients underwent a BDG procedure. Patients were stratified into CPB (n = 72; age = 202 days) and non-CPB (n = 34; age = 182 days) groups. Primary outcomes included operative mortality and postoperative complications as well as differences in long-term Kaplan-Meier survival. RESULTS: Median follow-up was 30 months. Preoperative patient characteristics were similar among patients despite the use of CPB. The most frequent indications for a BDG procedure were hypoplastic left heart syndrome (HLHS) (35.8%) and tricuspid atresia (TA) (17.9%). Median perfusion time was 73 minutes for CPB patients. Overall mortality was 0.9% and no deaths occurred among non-CPB patients (0.0% versus 1.4%; p > 0.99). Similarly, no significant differences existed between non-CPB patients and CPB patients with respect to overall complication rates (11.8% versus 18.1%; p = 0.57) or postoperative length of stay (7.0 [5.0-12.0] versus 7.0 [5.0-11.0] days; p = 0.38). Furthermore, 1-, 3-, and 5-year survival was high and similar between groups. CONCLUSIONS: The BDG procedure can be performed with no significant differences in operative mortality, morbidity, or use of resources, with or without CPB support. Long-term survival after the BDG procedure is high with both strategies. Performance of an off-pump BDG procedure should be considered a safe alternative to the conventional use of CPB for appropriately selected patients.

Pulmonary artery and conduit reintervention rates after norwood using a right ventricle to pulmonary artery conduit.

BACKGROUND: There is a high incidence of cardiovascular reinterventions in patients undergoing a Norwood procedure (NP). The goal of this study was to analyze the rate of pulmonary artery (PA) and conduit stenosis using the right ventricle (RV)-to-PA modification of the NP. METHODS: Patients who underwent a NP January 2005 to December 2009 were included. The procedure was performed with a ringed conduit sutured to a membrane to form a patch. The patch was sutured to the PA confluence, and the spatulated conduit was anastomosed to an appropriately sized right ventriculotomy. Rates of PA and conduit stenosis requiring reintervention were calculated based on cardiac catheterization data. RESULTS: Thirty-three patients with hypoplastic left heart syndrome underwent a NP. Perioperative mortality was 6% (2 of 33). Twenty-eight patients (85%) had a Glenn procedure 5 ± 1 months later, and 12 patients (36%) had a Fontan procedure 34 ± 2 months after the Glenn. Pulmonary artery stenosis occurred in 11 patients (33%), and RV-PA conduit stenosis occurred only in 2 patients (6%). One-year and 3-year actuarial survival rates were 82% and 77%, respectively. Both branch PAs showed good and symmetric growth at cardiac catheterization before Glenn. CONCLUSIONS: The NP with RV-PA conduit using a ringed graft and a pulmonary patch is a technique associated with a low rate of PA and conduit stenosis, and good outcomes.

Outcomes of reoperative aortic valve replacement after previous sternotomy.

OBJECTIVE: Increasingly, patients with previous sternotomy require aortic valve replacement. We compared outcomes of reoperative aortic valve replacement after previous sternotomy and primary aortic valve replacement by surgical era. Effect of initial cardiac operation on reoperative aortic valve replacement was also investigated. METHODS: Between January 1996 and December 2007, a total of 1603 patients undergoing elective aortic valve replacement were entered prospectively into our clinical database. Patients were divided into eras A (1996-1999), B (2000-2003), and C (2004-2007). A total of 191 patients (12%) had previous sternotomy for coronary artery bypass grafting (n = 88), coronary artery bypass grafting with aortic valve replacement (n = 16), aortic valve replacement with or without other aortic procedure (n = 70), and other cardiac procedures (n = 17). Mean ages were 66.5 +/- 13.1 years in reoperative group and 65.5 +/- 14.9 years in primary group. RESULTS: Mortality in reoperative group decreased significantly with time (A 15.4% vs B 15.1% vs C 2.0%, P = .004) and was equivalent to primary group in era C (3.5% vs 2.0%, P = .65). Major complications also significantly decreased with time in reoperative group (A 25.6% vs B 17.0% vs C 6.1%, P = .006). Importantly, patients had more comorbidities with time and increased preoperative risk in era C. There were no differences in outcome by initial cardiac operation in reoperative group. CONCLUSIONS: Reoperative aortic valve replacement now carries similar morbidity and mortality to primary replacement. Risk of reoperation is not affected by primary operation.

Rosai-Dorfman disease presenting as a pulmonary artery mass.

Rosai-Dorfman disease is rare and typically presents with cervical lymphadenopathy, but may manifest as extranodal disease. This disease is generally indolent and self-limited, but it carries a poor or fatal prognosis when it is advanced or when it involves and compresses vital structures. We present a case of Rosai-Dorfman disease affecting the pulmonary arteries in a 22-year-old woman with severe, symptomatic right heart failure.

Congenital heart disease surgery in the adult.

As a result of improved treatment of congenital heart disease (CHD) over the last half century, the number of patients reaching adulthood continues to grow. With increased success a challenging group of adults with unique anatomy and physiology, in addition to the usual effects of aging, has been created. All of these patients present unique and fascinating challenges, and their best care requires bridging pediatric and adult medical and surgical care. This review is a discussion of some of the more common surgical issues that arise in this evolving group of patients.

Endovascular repair of the thoracic aorta in the post-FDA approval era.

OBJECTIVE: Endovascular repair of thoracic aortic disease is rapidly progressing as an alternative to open surgical therapy. In March of 2005, the Gore TAG thoracic endoprosthesis (W. L. Gore & Associates, Inc, Flagstaff, Ariz) received Food and Drug Administration (FDA) approval for the treatment of descending thoracic aortic aneurysms. Subsequently, off-label use of the technology expanded to include additional thoracic aortic diseases. The purpose of this study was to examine whether the outcomes with this device changed after the inclusion and exclusion criteria of FDA-controlled trials no longer governed patient selection. METHODS: A retrospective analysis was performed on all patients who underwent endovascular repair of the thoracic aorta with the Gore TAG device at our institution between March 23, 2005, and September 8, 2006. RESULTS: Fifty consecutive patients with a broad range of aortic pathologic conditions were included in the study. The results in this group compared with those of the phase II trial included the following: length of stay, 7.5 versus 7.6 days (P = .97); intensive care unit stay, 3.7 versus 2.6 days (P = .61); 30-day mortality, 2.0% versus 1.5% (P = .68); spinal cord injury, 2% versus 3% (P = .89); stroke, 4% versus 4% (P = .67); early endoleaks, 26% versus 4% (P < .01); and late endoleaks, 18% versus 7% (P = .08). At 1 year, overall survival was 92% compared with 82% in the phase II trial. CONCLUSIONS: In the post-FDA approval era, endovascular stent-graft therapy is frequently applied to patients with more challenging thoracic aortic anatomy and a wide range of pathologic conditions. Our results in this group are similar to outcomes reported for patients with descending thoracic aortic aneurysm exclusively.

Model for end-stage liver disease predicts mortality for tricuspid valve surgery.

BACKGROUND: Patients undergoing tricuspid valve surgery have a mortality of 9.8%, which is higher than expected given the complexity of the procedure. Despite liver dysfunction seen in many patients with tricuspid disease, no existing risk model accounts for this. The Model for End-Stage Liver Disease (MELD) score accurately predicts mortality for abdominal surgery. The objective of this study was to determine if MELD could accurately predict mortality after tricuspid valve surgery and compare it to existing risk models. METHODS: From 1994 to 2008, 168 patients (mean age, 61 +/- 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using chi(2), Fisher's exact test, and area under the curve (AUC) analyses. RESULTS: Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96). CONCLUSIONS: The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.

Do you need to clamp a patent left internal thoracic artery-left anterior descending graft in reoperative cardiac surgery?

BACKGROUND: Dogma suggests optimal myocardial protection in cardiac surgery after prior coronary artery bypass graft surgery (CABG) with patent left internal thoracic artery (LITA) pedicle graft requires clamping the graft. However, we hypothesized that leaving a patent LITA-left anterior descending (LAD) graft unclamped would not affect mortality from reoperative cardiac surgery. METHODS: Data were collected on reoperative cardiac surgery patients with prior LITA-LAD grafts from July 1995 through June 2006 at our institution. With the LITA unclamped, myocardial protection was obtained initially with antegrade cardioplegia followed by regular, retrograde cardioplegia boluses and systemic hypothermia. The Society of Thoracic Surgeons National Database definitions were employed. The primary outcome was perioperative mortality. Variables were evaluated for association with mortality by bivariate and multivariate analyses. RESULTS: In all, 206 reoperations were identified involving patients with a patent LITA-LAD graft. Of these, 118 (57%) did not have their LITA pedicle clamped compared with 88 (43%) who did. There were 15 nonsurvivors (7%): 8 of 188 (6.8%) in the unclamped group and 7 of 88 (8.0%) in the clamped group (p = 0.750). Nonsurvivors had more renal failure (p = 0.007), congestive heart failure (p = 0.017), and longer perfusion times (p = 0.010). When controlling for independently associated variables for mortality, namely, perfusion time (odds ratio 1.014 per minute; 95% confidence interval: 1.004 to 1.023; p = 0.004) and renal failure (odds ratio 4.146; 95% confidence interval: 1.280 to 13.427; p = 0.018), an unclamped LITA did not result in any increased mortality (odds ratio 1.370; 95% confidence interval: 0.448 to 4.191). Importantly, the process of dissecting out the LITA resulted in 7 graft injuries, 2 of which significantly altered the operation. CONCLUSIONS: In cardiac surgery after CABG, leaving the LITA graft unclamped did not change mortality but may reduce the risk of patent graft injury, which may alter an operation.

Is mitral valve repair superior to replacement in elderly patients?

BACKGROUND: Mitral valve replacement is more frequently performed and perceived to be equivalent to repair in elderly patients, despite the superiority of repair in younger patients. Our objective was to compare mitral repair to replacement in elderly patients age 75 years or older. Patients younger than 75 years undergoing mitral valve surgery served as a reference population. METHODS: Consecutive elderly patients undergoing operation for mitral regurgitation at our institution from 1998 to 2006 were reviewed. Elderly patients (mean age, 78.0 +/- 2.8 years) who underwent mitral repair (n = 70) or replacement (n = 47) were compared with cohorts of young patients (mean age, 58.9 +/- 9.3 years) who underwent repair (n = 100) or replacement (n = 98) during the same period. Patient details and outcomes were compared using univariate, multivariate, and Kaplan-Meier analyses. RESULTS: Mitral replacement in elderly patients had higher mortality than repair (23.4%, 11 of 47 versus 7.1%, 5 of 70; p = 0.01) or as compared with either operation in the reference group (p < 0.0001). Postoperative stroke was higher in elderly replacement patients compared with repair (12.8%, 6 of 47 versus 0%; p = 0.003) or compared with either young cohort (p = 0.02). Compared with elderly repair patients, elderly replacement patients had more cerebrovascular disease (21.3%, 10 of 47 versus 4.3%, 3 of 70; p = 0.005) and rheumatic mitral valves (21.3%, 10 of 47 versus 0%; p = 0.0001). In the young group, overall complication and mortality were no different between replacement and repair. Long-term survival favored repair over replacement in elderly patients (p = 0.04). One elderly repair patient experienced late recurrence of persistent mitral regurgitation. CONCLUSIONS: In patients age 75 years or older, mitral repair is associated with a lower risk of mortality, postoperative stroke, and prolonged intensive care unit and hospital stay compared with mitral replacement. Mitral repair can be performed in preference over replacement even in patients older than the age of 75.

Cardiac injury during resternotomy does not affect perioperative mortality.

BACKGROUND: Cardiac injury at the time of resternotomy is a complication faced by all cardiac surgeons, although little is known about its effects on morbidity and mortality. This study was designed to address these questions. STUDY DESIGN: Resternotomies performed at the University of Virginia from 1996 to 2005 were identified. Operative notes were reviewed, and any injury during resternotomy to the heart, great vessels, or bypass grafts was recorded. Perioperative complications and mortality were recorded using the Society of Thoracic Surgeons National Database. RESULTS: In the 11-year period studied, 612 resternotomies were performed out of 7,872 total adult cardiac procedures (7.8%). Fifty-six patients (9.1%) had an injury sustained during resternotomy and initial dissection. Injury to grafts was most common (46.4%), with mammary arteries comprising 21% of the total and vein grafts, 25%. The right ventricle was the second most commonly injured structure (21.4%). There were no significant differences in overall nonadjusted mortality in the injured group compared with that in the noninjured group (8.9% versus 10.2%, p=0.66). Multivariate analysis demonstrated third-time resternotomy to be an independent risk factor for cardiac injury (p=0.04). CONCLUSIONS: Cardiac injury at the time of resternotomy is not associated with an increase in perioperative morbidity or mortality. Third-time resternotomy is an independent risk factor for cardiac injury, so vigilance and adequate preparation are paramount in these patients.

Timing of stroke after cardiopulmonary bypass determines mortality.

BACKGROUND: Stroke is an important complication of cardiopulmonary bypass (CPB). This study determined if the timing of stroke events after CPB predicted stroke-related mortality or rehabilitation needs at hospital discharge. METHODS: We performed a retrospective review of 7201 consecutive cardiac surgical patients during a 10-year period and identified 202 strokes. Postoperative stroke after CPB was classified as early (< or = 24 hours) or late (> 24 hours). Data were collected on patient characteristics, intraoperative variables and outcomes, postoperative course, stroke severity, and discharge status, including death from stroke. Logistic regression analysis was used to assess the relationship between the timing of stroke and discharge status after adjusting for clinically relevant factors. RESULTS: The stroke incidence was 2.8%. Postoperative strokes occurred within 24 hours in 22.8% (46 of 202) and after 24 hours in 77.2% (156 of 202). Factors found in logistic regression analysis to be independently associated with stroke-related death included stroke within 24 hours postoperatively (odds ratio [OR], 9.16; p < 0.0001), preoperative chronic renal insufficiency (OR, 4.46; p = 0.01), and National Institute of Health Stroke Scale (NIHSS) score (OR, 1.16 per NIHSS point increase; p < 0.0001). Among survivors, early stroke was associated with greater rehabilitation needs (p < 0.001). CONCLUSIONS: Early stroke after CPB is independently associated with higher stroke-related death and is associated with increased need for skilled rehabilitation at discharge. Neuroprotective strategies aimed at reducing early postoperative stroke may positively impact death and neurologic disability after CPB.

Predicting operative mortality after surgery for ischemic cardiomyopathy.

BACKGROUND: Ischemic cardiomyopathy accounts for as many as 70% of cases of heart failure with no clear algorithm for the treatment. We assessed the operative risks and mortality of various surgical options: coronary artery bypass grafting (CABG), CABG and mitral valve repair (CABG/MVR), and left ventricular remodeling (LVR) with or without CABG. We hypothesized that additional procedures increased the operative risk. We determined whether preoperative variables (eg, urgency of operation) impacted the surgical outcome. METHODS: A retrospective analysis of University of Virginia patients from January 2000 until September 2006 was undertaken. Patients with CABG and an ejection fraction less than 35%, ischemic mitral regurgitation by operative characterization, and patients with LVR were identified. The Society of Thoracic Surgeons database risks, complications, and outcomes as well as degree of revascularization, quality of targets, and type of additional procedures were analyzed. Incomplete revascularization was defined as a planned bypass not performed. Poor targets were defined as per the operative note. RESULTS: In all, 382 patients were identified (220 CABG, 97 CABG/MVR, and 65 LVR). The overall operative mortality was 7.9%. Mortality was 9.1% for CABG, 8.2% for CABG/MVR, and 3.1% for LVR. Preoperative risk factors for mortality included diabetes mellitus (p = 0.05), previous cerebrovascular disease (p = 0.05), and chronic renal dysfunction (p = 0.03). Patients with emergency operations had a significantly increased mortality (p < 0.001) as did patients with intra-aortic balloon pumps (p = 0.015). CONCLUSIONS: Additional procedures such as MVR or LVR did not add to the operative risk of CABG for ischemic cardiomyopathy. Only preoperative comorbidities and emergency operations increased operative mortality.

Anomalous origin of the right coronary artery: right internal thoracic artery to right coronary artery bypass is not the answer.

OBJECTIVE: Anomalous origin of the right coronary artery from the opposite sinus of Valsalva can be a lethal congenital anomaly. Right internal thoracic artery grafting to the right coronary artery is prone to fail in this circumstance. We sought to describe alternative surgical techniques. METHODS: Retrospective analysis identified 5 adult and pediatric patients in our database. We reviewed the surgical techniques used to repair this anomaly. On the basis of our experience, we describe our management technique. RESULTS: There were no operative deaths, and postoperative computed tomographic scans demonstrated widely patent repairs in all patients. Two patients with previous right internal thoracic artery to right coronary artery grafts presented with occlusion of the right internal thoracic artery. Short-term follow-up demonstrated continued patency. CONCLUSION: Right internal thoracic artery grafting fails in this circumstance, and alternative surgical options provide a good outcome.