Bilateral versus single internal mammary artery in diabetic patients: systematic review and meta-analysis.

OBJECTIVES: Data on bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) on diabetics were analyzed; This is the only meta-analysis, the last 7 years. METHODS: Medline through PubMed/EMBASE/CINHAL and the Cochrane Central Register of Controlled Trials; 179 articles were studied; 19 studies deemed suitable and were included in the analysis. RESULTS: The mortality was 2.41% for BIMA versus 1.71% for SIMA (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.74-1.22). Postoperative reopening for bleeding was higher at 3.75% for BIMA versus 2.91% for SIMA (OR = 1.49; 95% CI: 1.15-1.93). The incidence of MI was 0.87% for BIMA versus 0.83% for SIMA (OR = 0.73; 95% CI: 0.37-1.44). Deep sternal wound infection was 3.02% for BIMA and 1.95% for SIMA (OR = 1.57; 95% CI: 1.26-1.95). When skeletonized, the incidence of DSWI was 2.5% for BIMA versus 2.41% for SIMA. There was a significant difference at 5-year survival favoring the BIMA, 85.15% BIMA versus 80.77% SIMA (OR = 1.79; 95% CI: 1.60-2.01). The 10-year overall survival was 74.04% BIMA versus 61.57% SIMA (OR = 1.79; 95% CI: 1.61-1.98). The 15-year survival was 47.08% for BIMA versus 37.06% for SIMA (OR = 1.69; 95% CI: 1.52-1.88). CONCLUSIONS: Postoperative bleeding was higher in BIMA group. Bilateral internal mammary artery in diabetic patients should be carried out in a skeletonize fashion, to reduce DSWI. There is a survival benefit of using BIMA in diabetics within 5 years of surgery; it remains significant up to 15 years.

Up-to-Date, Skeletonized or Pedicle Bilateral Internal Mammary Artery; Does It Matter?

PURPOSE: In this article, we reported on the up-to-date literature regarding skeletonized bilateral internal mammary artery (BIMA) flow and the effect on sternal perfusion. We also reviewed the pros and cons of the skeletonization technique versus the conventional pedicle technique for harvesting the BIMA. METHODS: We performed an up-to-date review using the PubMed database, with a specific focus on the contemporary published literature. RESULTS: BIMA skeletonization can preserve the sternal microcirculation, minimize tissue damage, and maintain blood supply to the chest wall at the tissue level. This effect is also apparent in diabetics. Deep sternal wound infection (DSWI) rates are significantly less with skeletonization versus the conventional pedicle technique and are comparable to single internal mammary artery harvesting. CONCLUSIONS: Contemporary large-scale studies demonstrate that skeletonization of the BIMA increases conduit length, provides superior flow, reduces the incidence of DSWIs, and improves late survival. Hopefully, this review will increase awareness of the compelling evidence in favor of using skeletonized internal mammary arteries and stimulate increased uptake of BIMA revascularization surgery.

Post-cardiotomy open chest management. A single-unit experience.

OBJECTIVE: Post-cardiotomy open chest management is used either for salvage or as a planned therapeutic option in patients with low cardiac output, hemorrhage, or intractable arrhythmias. We reviewed our experience with these patients. METHODS: Over a 3-year period, 2534 adult cardiac patients were operated on and 35 (1.4%) had delayed sternal closure. The median age was 72 years (range 46-86 years) and mean logistic EuroSCORE I was 11.29 (range 1.33-84.99). The patients were divided into two groups: group A (22/35, 62.9%) left the operating room without sternal closure due to hemodynamic instability after coming off cardiopulmonary bypass; group B (13/35, 37.1%) had a resternotomy and sternal closure was delayed due to acute deterioration in the cardiac intensive care unit. RESULTS: The median intensive care unit stay was 17 days (range 2-70 days). Mortality was 25.7% (9 patients). All survivors were followed-up for at least 2 years, with a 2-year survival rate of 57.1%. Overall mortality was broadly similar in both groups. There was a high rate of postoperative complications in both groups, including chest sepsis (77%), liver failure (14.3), renal failure requiring renal replacement therapy (42.9%), sternal wound infection (28.6%), gut ischemia (2.9%), cerebrovascular accident (11.4), and multiorgan failure (31.4%). CONCLUSIONS: Some may argue that open chest management is an acceptable salvage procedure, however, follow-up demonstrated significant adverse cardiac or cerebrovascular events in a short period following discharge, thus delayed sternal closure is really a salvage procedure but useful in centers without access to extracorporeal membrane oxygenation.

Concomitant off-pump coronary artery bypass grafting and total thyroidectomy for a large retrosternal goitre: a case report and review of the literature.

A 76-year-old male presented with angina and a large retrosternal goitre causing marked dyspnoea. Coronary angiography revealed triple vessel disease and moderately impaired left ventricular function. CT imaging demonstrated a substantial multinodular goitre extending into the posterior mediastinum to the level of the carina, with associated compression of the trachea and oesophagus. Preoperative thyroid function tests showed euthyroid state. The patient subsequently underwent off-pump coronary artery bypass grafting (OPCABG) ×2 with concomitant total thyroidectomy. A thyroid mass of dimensions 19 cm × 16 cm × 5.5 cm and weight 439 g was confirmed to be a multinodular goitre. Postoperative complications included bilateral recurrent laryngeal nerve damage, hypocalcaemia and ventilator-associated pneumonia. The patient was discharged 36 days postoperatively and remained asymptomatic at 1 year follow up. This case provides further evidence that concomitant OPCABG and thyroidectomy for the treatment of large retrosternal goitre can be safely and effectively performed, provided that perioperative levels of thyroid hormones are maintained at euthyroid or hypothyroid levels.

Non-surgical bleeding in cardiac surgery.

Bleeding is an occurrence stemming from complex interactions encountered in cardiac surgery and is often attributed to the perioperative administration of anti-thrombotic products if inadequate surgical haemostasis is excluded. Very occasionally, bleeding does not fit the norm and the aetiology is not a lack of surgical prolene or an iatrogenic-induced coagulopathy. Patients who present for cardiac surgery should be questioned carefully for a history of bleeding; however, patients at risk are not always identified. This case presents a series of haemorrhagic events incorrectly labelled as surgical complications resulting from an uncommon but not insignificant undiagnosed condition. The existing literature outlining protocols to safely manage patients with haemophilia during the perioperative cardiac surgical period is discussed in this report. This case explicitly demonstrates the importance of preoperative identification to avoid the morbidity that can result from cardiac surgery in an undiagnosed haemophilic patient.

Current randomized control trials, observational studies and meta analysis in off-pump coronary surgery.

The off-pump literature is divided into three eras: the "early phase" with results favouring off-pump surgery supported with randomized control trials (RCTs) mainly from Bristol, UK; an "intermediate phase" dominated by the results of the ROOBY trial and finally a more "contemporary phase" whereby the off/on-pump argument is unsettled. Although the literature has failed to project an overall superiority of off-pump versus on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies are concluding that the incidence of a stroke is less than 1 % when an aortic off-pump techniques (especially the non-touch technique) are advocated in patients with diseased ascending aorta. Furthermore, off-pump combined with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities.The current review attempts to bring an insight onto the last ten years knowledge on the on/off-pump debate, with an aim to draw some clear conclusions in order to allow practitioners to reflect on the subject.

The impact of off-pump surgery in end-organ function: practical end-points.

Most surgeons perform coronary bypass surgery with the aid of cardiopulmonary bypass, which inflicts a massive systemic inflammatory response to the body leading to adverse clinical outcome. In an attempt to make CABG less invasive, interest have been diverted to the off pump technique.The current review attempts to bring an insight onto the last ten years knowledge on the off-pump impact in end organ function, with an aim to draw some clear conclusions in order to allow practitioners to reflect on the subject.

A novel approach: how an intracoronary shunt proved to be lifesaving.

Outcomes and complications following internal massage in cardiac surgery are unknown due to the lack of cumulative effort to capture those events and subsequently developing a registry. Therefore, under the circumstances there are no algorithms defined in the literature. This case report outlines the importance of sound decision-making under pressure in order to achieve a favourable outcome. A potential solution is outlined to a very complex and rare problem: anastomotic disruption during internal cardiac massage in an intensive care unit setting, demonstrating the use of an intracoronary shunt for initial stabilization prior to a definitive procedure.

Which is the best graft for the right coronary artery?

Bilateral internal mammary arteries directed to the left coronaries are gaining popularity; an increasing level of evidence nowadays supports this surgical strategy. On the other hand, composite right internal mammary artery, radial artery, and gastroepiploic artery targeting high-grade stenotic lesions in the right coronary artery system may confer improved mid- and long-term patency compared to long saphenous veins. This analysis looks into the evidence comparing data of the third best available conduit for grafting the right coronary artery, and by extrapolating this report, compares total arterial revascularization vs. conventional coronary artery bypass grafting.

Rapid pannus formation after few months of obstructing aortic mechanical prosthesis.

We report a rare case of a prosthetic aortic valve obstruction due to pannus formation only 3 months following aortic and mitral valve replacement. Fragments of asymmetrical pannus formation affected one of the leaflets of the bi-leaflet mechanical valve; the leaflet appeared immobile due to pannus ingrowth into the mechanical skeleton resulting in encroachment of the leaflet, which in turn became immobile. The patient successfully underwent emergency redo-aortic valve replacement.

A case of focal lung infarction following right upper lobectomy in case of undeveloped lung fissure.

We present a case of infarction of residual upper lobe tissue during right upper lobectomy. We believe that although the blood supply to the upper lobe had been isolated and divided in order to perform the right upper lobectomy, residual right upper lobe had been left behind secondary to "poorly estimated" staple separation of the upper from the middle lobe in a patient with non-developed oblique fissure. We suggest that in this situation the upper lobe bronchus should be identified and clamped and the lung re-inflated in order to accurately demarcate the borders of the upper and middle lobe prior to the application of the stapler to prevent infarction of residual upper lobe tissue. Therefore, this case emphasises that routine lung inflation during fissure development in right upper lobectomy may prevent unpredictable complications.

Off-pump coronary surgery: current justifications.

Although the literature has failed to project an overall superiority of off-pump vs. on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies have concluded that the incidence of a stroke is less than 1 % when anaortic off-pump techniques are advocated in patients with diseased ascending aorta. Furthermore, off-pump techniques or their combination with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities. However, despite this, controversy still exists among the cardiac surgery community in terms of the benefit of this technique and its safety; hence, off-pump is becoming out of fashion. In this review paper, by looking at a "marginal group of patients" (elderly, high risks, atherosclerotic aortas) we attempt to re-establish and justify this technique and re-invent its usage.

Ascending aorta thrombus: A diagnostic and treatment dilemma.

Due to its position, a mass lesion in the ascending aorta poses a diagnostic and treatment dilemma. We describe the management of a symptomatic mass in the ascending aorta in a 35-year-old man who presented with a cerebrovascular accident.

Aspergillus infection in pulmonary cavitating lesions with right atrial myxoma.

Cardiac myxomas are rare primary tumors with varied clinical presentations that may pose a diagnostic challenge. Here, we describe the case of a 21-year-old man with multiple cavitating lung lesions with aspergillosis and underlying right atrial myxoma, who presented with hemoptysis and weight loss. He was successfully treated with right atrial myxoma resection and antifungal agents, with no recurrence or complications after one year of follow-up.