Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry.

Background and objective: The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study. Methods: We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported. Results: The study cohort (n = 1323) was aged 63 ± 9 years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%). Conclusions: This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01526-3.

Concomitant transcatheter transfemoral double native valve replacement for severe aortic stenosis and severe mitral stenosis with mitral annular calcification.

Concomitant mitral and aortic valve stenosis in a patient with mitral annular calcification and porcelain aorta poses a unique problem to the surgical team. Transcatheter aortic and mitral valve replacements in native valves offer a viable option for such selected group of patients. We present the case of a 54-year-old male who presented with severe aortic stenosis (AS) and severe mitral stenosis (MS) but was deemed high risk for surgery owing to intense calcification of the aorta and mitral annular calcification, and successfully underwent transcatheter double native valve replacement.

Single-center experience of 105-minimalistc transfemoral transcatheter aortic valve replacement and its outcome.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) increases worldwide, and indications expand from high-risk aortic stenosis patients to low-risk aortic stenosis. Studies have shown that minimalistic TAVR done under conscious sedation is safe and effective. We report single-operator, the single-center outcome of 105 minimalist transfemoral, conscious sedation TAVR patients, analyzed retrospectively. METHODS: All patients underwent TAVR in cardiac catheterization lab via percutaneous transfemoral, conscious sedation approach. A dedicated cardiac anesthetist team delivered the conscious sedation with a standard protocol described in the main text. The outcomes were analyzed as per VARC-2 criteria and compared with the latest low-risk TAVR trials. RESULTS: A total of 105 patients underwent transcatheter aortic valve replacement between July 2016 to February 2020. The mean age of the population was 73 years, and the mean STS score was 3.99 ± 2.59. All patients underwent a percutaneous transfemoral approach. Self-expanding valve was used in 40% of cases and balloon-expandable valve in 60% (Sapien3™ in 31% and MyVal™ in 29%) of cases. One patient required conversion to surgical aortic valve replacement. The success rate was 99 percent. The outcomes were: all-cause mortality: 0.9%, stroke rate 1.9%, New pacemaker rate 5.7%, 87.6% had no paravalvular leak. The mild and moderate paravalvular leak was seen in 2.8% and 1.9%, respectively. The mean gradient decreased from 47.5 mmHg to 9 mmHg. The average ICU stay was 26.4 h, and the average hospital stay was 5.4 days. Our outcomes are comparable with the latest published low-risk trial. CONCLUSION: Minimalist, conscious sedation, transfemoral transcatheter aortic valve replacement when done following a standard protocol is safe and effective.

Left atrial high-grade rhabdomyosarcoma; an unusual location.

A 63-year-old diabetic and hypertensive lady presented in New York Heart Association class III-IV dyspnea on exertion. Echocardiography showed a large mass attached to the anterior mitral leaflet and the base of the interatrial septum. After removal of the mass and excision of the anterior and posterior mitral leaflets, a bioprosthetic valve was deployed. The postoperative course was uneventful. Histopathology showed that the tumor was a high-grade rhabdomyosarcoma. Although it is a highly lethal tumor, surgical removal was indicated to relieve dyspnea, clarify the diagnosis, and improve short-term survival. Our patient survived for 8 months after surgical excision.

Incidence of new diabetes following CABG surgery: Analysis of a single centre registry data.

BACKGROUND: About 40-50% of patients undergoing coronary artery bypass graft (CABG) surgery have diabetes. The prevalence of impaired glucose tolerance (IGT) is also high in this group, however, incidence of new diabetes following CABG surgery is unknown. OBJECTIVES: To determine incidence of new diabetes and the impact on ICU and hospital stay in patients undergoing CABG surgery in India, we performed a registry-based study. METHODS: Prospectively collected data among consecutive adult cardiac surgical patients who underwent CABG surgery at a single hospital were analyzed. Descriptive statistics are reported. RESULTS: We recruited 1559 consecutive patients (men 1355, women 204) and analyzed data among 933 non-diabetic patients. Patients with known diabetes (n = 626, 40%) were excluded. 57 (6.1%) of the 933 non-diabetic patients developed persistently high glucose levels at discharge with incidence rate of 61 + 5/1000. Patients who developed diabetes had similar age and body mass index vs those who did not, but had greater preoperative IGT (44.6 vs 13.7%) and more time-period in intensive care unit (102.0 + 75 vs 80.2 + 29 hours) as well as in hospital (11.7 + 5.7 vs 9.6 + 2.4 days) (p < 0.001). CONCLUSION: In a significant proportion of non-diabetic patients diabetes is unmasked after CABG. This is more likely in those with impaired glucose tolerance and prolonged period in intensive care and hospital.

Left main coronary artery bifurcation angioplasty and stenting after aortic valve replacement: a case report.

A 43-year-old young lady had closed mitral valvotomy (CMV) in 1994 and aortic valve replacement (AVR) in June 2007. Shortly thereafter, she presented with unstable angina in October 2007 with on-going pain and haemodynamic instability. Coronary angiogram showed tight left main bifurcation stenosis in a left dominant system. Having had open heart surgery (AVR) recently, and being on oral anticoagulation, with on-going ischaemia and unstable haemodynamics, percutaneous coronary intervention (PCI) was considered the most suitable option. She underwent successful PCI with two drug-eluting stents (T-stenting) to left main bifurcation through transradial approach and intra-aortic balloon support. Clinically she remained symptom free and coronary angiogram after 5 months and 15 months of follow-up showed patent stents. This case demonstrates the acute effectiveness of PCI for the treatment of critical left main disease following open heart surgery in patients who are not appropriate surgical candidates.

Oncolytic vaccinia virus expressing the human somatostatin receptor SSTR2: molecular imaging after systemic delivery using 111In-pentetreotide.

Oncolytic vaccinia viruses (VV) have demonstrated tumor specificity, high levels of transgene expression, and anti-tumor effects. The ability to visualize vector biodistribution noninvasively will be necessary as gene therapy vectors come to clinical trials, and the creation of a VV that can both treat tumors and permit noninvasive imaging after systemic delivery is therefore an exciting concept. To facilitate imaging, a VV expressing the human somatostatin receptor type 2 (SSTR2) was created. Cells infected with the SSTR2-expressing VV or controls were incubated with the somatostatin analog 111In-pentetreotide with or without an excess of nonradiolabeled pentetreotide. The SSTR2-infected cells bound 111In-pentetreotide sixfold more efficiently than control virus-infected cells and this binding was specifically blocked by nonradiolabeled pentetreotide. Nude mice bearing subcutaneous murine colon CA xenografts were injected intraperitoneally with the SSTR2-expressing VV or control VV. After 6 days, mice were injected with 111In-pentetreotide and imaged. Mice were sacrificed and organs collected and counted in a gamma counter. The uptake of radioactivity in tumors and normal tissues (percentage injected dose per gram) and tumor-to-normal tissue ratios were determined. Tumors infected with the SSTR2-expressing VV accumulated significantly higher concentrations of radioactivity compared to tumors in animals receiving the control virus. SSTR2-infected tumors were visible on imaging 6 days after VV injection and could be visualized for up to 3 weeks post-viral injection using repeat injections of 111In-pentetreotide. This reporter gene imaging strategy could be a very effective method to visualize vector distribution, expression, and persistence over time and enhances the potential of VV as a novel anti-cancer therapeutic.