Long-term survival after xenograft versus homograft aortic root replacement: Results from a prospective randomized trial.

OBJECTIVE: The study objective was to investigate the long-term survival of patients undergoing xenograft versus homograft full root aortic valve replacement. METHODS: A total of 166 patients requiring aortic valve surgery were randomized to undergo the Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis (N = 90) or a homograft (N = 76) full root aortic valve replacement between 1997 and 2005 in a single institution. Six patients randomly assigned to the homograft crossed over to the Freestyle bioprosthesis because of the unavailability of suitably sized homografts. All surgeons were required to adhere to the standard surgical technique for homograft root implantation previously described. Follow-up was 98.5% complete. RESULTS: The mean age of the study population was 65 ± 8 years. Coronary artery bypass grafting was associated with root aortic valve replacement in 76 of 166 patients (46%, P = not significant between groups), and overall hospital mortality was 4.8% (8/166, P = not significant between groups). Median follow-up was 13.8 years (range, 0-21.8 years; 2033 patient-years). The Kaplan-Meier survival analysis showed that there was no significant difference in overall survival between the 2 arms at 5, 10, and 15 years. Twenty-year survival was 28.3% ± 5% for the Freestyle group versus 25.1% ± 5.7% for the homograft group (P = .90), which was comparable to the age- and sex-matched UK general population. The freedom from aortic valve reoperation at 20 years was comparable for the Freestyle group versus the homograft group (67.9% ± 8.8% vs 67.2% ± 10.3%, respectively; P = .74). CONCLUSIONS: This is the first study to investigate the long-term survival of xenograft versus homograft full root aortic valve replacement from a prospective randomized trial. The observed 20-year overall survival and freedom from aortic valve reoperation serve as a benchmark for future studies on interventions for aortic valve disease in the elderly.

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: a case-control study of 1526 patients.

OBJECTIVE: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG. METHODS: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes. RESULTS: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46). CONCLUSIONS: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

Predictors of survival after gastrointestinal complications in bypass grafting.

Between April 2001 and December 2005, data were collected prospectively from 2,320 consecutive patients who underwent first-time coronary artery bypass. Logistic multiple regression analyses were carried out to determine the independent predictors of gastrointestinal complications and death. There were 65 major gastrointestinal complications identified in 65 (2.8%) patients: paralytic ileus in 15, mesenteric ischemia in 12, upper gastrointestinal hemorrhage in 16, lower gastrointestinal hemorrhage in 8, small bowel obstruction in 5, pseudoobstruction in 5, and others in 4. The 30-day mortality was 21.5% (14 patients). Female sex, preoperative creatinine >200 µmol·L(-1), previous gastrointestinal pathology, low cardiac output, readmission to the intensive care unit, postoperative pulmonary complications, arrhythmias, hemofiltration, and reoperation were independent predictors of major gastrointestinal complications. Independent risk factors for death were readmission to the intensive care unit, the need for hemofiltration, reoperation, and ischemic bowel. Careful hemodynamic control and optimization of perioperative organ perfusion are important to minimize the mortality associated with major gastrointestinal complications after coronary artery bypass.

Ruptured sinus of Valsalva aneurysm presenting as ST-elevation myocardial infarction.

BACKGROUND: A 52-year-old man presented with central chest pain, which he had experienced for 8 h. He had no other associated symptoms and no prior history of cardiovascular disease. INVESTIGATIONS: Electrocardiography, chest radiography, coronary angiography, aortic angiography, echocardiography, CT thorax with contrast. DIAGNOSIS: Ruptured aneurysm of the sinus of Valsalva. MANAGEMENT: Emergency sternotomy and pericardiotomy, followed by aortic root replacement.

Does perioperative administration of thyroid hormones improve outcome following coronary artery bypass grafting?

The question addressed in this review is whether supplementation with thyroid hormones during the perioperative period improves the outcome of patients undergoing coronary artery bypass surgery. Altogether 88 relevant papers were identified using the below mentioned search, seven papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that although widespread interest has been shown on the use of thyroid hormones in the perioperative period, and the effect of cardiopulmonary bypass on thyroid hormone metabolism widely studied, there is no substantial evidence to justify routine use of thyroid hormones in patients undergoing coronary artery bypass grafting.

Propensity score analysis of early and late outcome after redo off-pump and on-pump coronary artery bypass grafting.

BACKGROUND: The purpose of this study was to compare early and late results of redo-CABG with (redo-ONCAB) and without (redo-OPCAB) cardiopulmonary bypass. METHODS: From April 2001 to September 2006 redo-CABG was performed in 110 patients (redo-ONCAB=50 and redo-OPCAB=60). Applying the propensity score, 43 OPCAB patients were matched with 43 ONCAB patients. The mean EuroScore was 5+/-4.7 and 5+/-3.4 for redo-ONCAB and redo-OPCAB, respectively (p=0.5). The number of diseased coronary arteries was 3+/-0.5 and 2+/-0.8 in redo-ONCAB and redo-OPCAB, respectively (p<0.01). RESULTS: Twelve patients underwent OPCAB through anterior thoracotomy while the rest of the patients (n=74) underwent median sternotomy. Mean number of grafts performed was 3+/-0.8 in redo-ONCAB and 2+/-0.6 in redo-OPCAB (p<0.05). The need for postoperative insertion of intra-aortic balloon pump (IABP) was higher (p=0.02) in redo-ONCAB (n=9, 21%) than redo-OPCAB (n=1, 2%). The duration of postoperative ventilation was 55+/-98.7 h for redo-ONCAB and 10+/-12.8h for redo-OPCAB (p=0.008). No differences were found in the incidence of other postoperative complications. The 30-day mortality rate was 6.9% for redo-ONCAB (n=3) and 2.3% redo-OPCAB (n=1; p=NS). Mean follow-up for redo-ONCAB was 30+/-21.3 months (range 0.1-63 months) and that of redo-OPCAB was 37+/-19.2 months (0.1-62.5 months). Actuarial survival at 5 years was 87+/-5.5% for redo-ONCAB and 95+/-3.2% for redo-OPCAB (p=0.17). Event-free survival was 71+/-8.0% for redo-ONCAB and 78+/-7.2% for redo-OPCAB (p=0.32). CONCLUSION: OPCAB is an acceptable strategy in selected patients requiring redo-CABG. Employing a strategy of OPCAB for those patients with 2 or fewer lesions and ONCAB for those with more diffuse disease, redo-OPCAB and redo-ONCAB have similar early and late outcomes.

Non-anastomotic avulsion of a left internal mammary artery graft--a rare complication of minimally invasive direct coronary artery bypass surgery.

OBJECTIVE: To describe a rare complication of minimally invasive coronary artery bypass surgery. METHOD: Case report. RESULTS: We present a 72-year-old patient with a left anterior descending artery stenosis who underwent elective minimally invasive direct coronary artery bypass (MIDCAB) surgery. Three months post-operatively he developed an anterior chest wall haematoma with electrocardiographic and enzyme evidence of myocardial ischaemia, though without haemodynamic embarrassment. Surgical exploration revealed non-anastomotic avulsion of the LIMA graft, which was bleeding freely into the left hemithorax. CONCLUSIONS: Minimally invasive direct coronary artery bypass surgery is now widely practised. Post-operative interruption of the left internal mammary artery graft is uncommon and avulsion of the graft proximal to the anastomosis with the left anterior descending artery has only been described in the literature on three occasions. This complication has been reported once in the setting of conventional bypass surgery and twice in the setting of minimally invasive direct coronary artery bypass surgery. In all of these cases, abrupt graft failure resulted in significant haemodynamic and/or ischaemic compromise, and all occurred within two weeks of surgery. Clinicians should be reminded of this rare though potentially catastrophic complication of MIDCAB surgery.

Mid-term pattern of survival, hemodynamic performance and rate of complications after medtronic freestyle versus homograft full aortic root replacement: results from a prospective randomized trial.

BACKGROUND AND AIM OF THE STUDY: The full homograft root replacement has been regarded as the 'gold standard' for aortic valve replacement (AVR). Xenograft full root AVR may offer similar theoretical advantages, but no prospective randomized trials to compare the two valve substitutes have been reported to date. METHODS: A total of 147 patients (mean age 66.2 years; range: 40-82 years) was randomized to undergo either Medtronic Freestyle (group F; n = 80) or homograft (group H; n = 67) root AVR. Coronary artery bypass grafting was associated with root AVR in 55 patients (37.4%). Follow up included routine clinical and echocardiographic assessments. RESULTS: Overall, there were seven early deaths (4.8%). The early mortality rate for isolated root AVR was 2.1% in group F (1/47) and 2.2% in group H (1/45) (p = NS). There were four late deaths in group F, and two in group H. Actuarial survival was 83+/-5% and 84+/-4% (p = NS) at five years, in groups F and H, respectively. No patient required reoperation on the aortic valve. Overall, there were eight thromboembolic events and six anticoagulant-related bleeding events; these were equally divided between the two groups. After a median follow up of 45 months, most patients in both groups were in NYHA class I, and the mean trans-aortic gradient was 6+/-1 mmHg in group F and 5+/-2 mmHg in group H (p = NS). Mild aortic regurgitation was recorded in 1/26 patients (4%) of group F, and in 1/16 (6%) of group H. CONCLUSION: The Medtronic Freestyle porcine xenograft appears to be a good alternative to homografts for full aortic root replacement, at least in the mid term.