Risks and Outcomes of Reoperative Cardiac Surgery in Patients With Patent Bilateral Internal Thoracic Artery Grafts.

BACKGROUND: Reoperative cardiac surgery in patients with patent bilateral internal thoracic artery (ITA) grafts is technically challenging. METHODS: From 2008 to 2017, of 7640 patients undergoing reoperative cardiac surgery, 116 (1.5%) had patent bilateral ITA grafts, including 28 with a right ITA crossing the midline. Mean age was 70 ± 9.6 years, and 111 patients (96%) were men. Reoperations included isolated coronary artery bypass grafting (n = 11), isolated valve (n = 55), valve + coronary artery bypass grafting (n = 26), and other procedures (n = 24). Clinical details, intraoperative management, and perioperative outcomes were analyzed. RESULTS: Aortic cannulation was central in 64 patients (56%) and through the femoral or axillary artery in 50 (44%). Four patients (3.4%) had planned transection and reattachment of ITAs crossing the midline, and 4 (3.4%) had ITA injuries, all right ITAs, 3 crossing the midline; 3 were repaired with an interposition vein graft, and 1 was managed by translocating the right ITA as a Y-graft off another graft. Patent ITAs were managed by atraumatic occlusion during aortic clamping in 90 patients (78%) and by systemic cooling without ITA occlusion in 19. There were 6 operative deaths, all due to low cardiac output syndrome (5.2%); 4 strokes (3.4%); and 5 cases of new postoperative dialysis (4.3%). CONCLUSIONS: Risk of injury to bilateral ITA grafts during reoperation is high, and right ITAs crossing the midline present a particular risk of injury and should inform planning for primary coronary artery bypass grafting. Risk of low cardiac output syndrome underscores the challenge of ensuring adequate myocardial protection.

Right Internal Thoracic Artery Patency Is Affected More by Target Choice Than Conduit Configuration.

BACKGROUND: Although coronary artery bypass grafting using bilateral internal thoracic arteries (ITA) maximizes long-term survival, knowledge of the effect of different right ITA (RITA) inflow configurations on graft patency is limited. We have compared RITA occlusion among these configurations and identified its risk factors while adjusting for outflow coronary target location. METHODS: From January 1972 to January 2016, of 7092 patients undergoing bilateral ITA grafting at a single center, 1331 received one ITA to the left anterior descending coronary artery and had one or more evaluable postoperative coronary angiograms: 835 (63%) in situ, 496 free RITA grafts (311 [63%] originating from aorta; 98 [20%] left ITA [LITA], 76 [15%] saphenous vein graft, 11 [2%] radial graft). RITA occlusion reported on 1983 angiograms performed a median of 5.8 years later was estimated using nonlinear mixed-effects longitudinal modeling. RESULTS: RITA patency was 90% at 1 year, 87% at 5 years, and 86% at 10 and 15 years. At 15 years, in situ RITA patency was 91% and free RITA patency from aorta was 91%, LITA 89%, and saphenous vein graft 77%. After adjusting for coronary target location and degree of stenosis, occlusion was similar in free RITAs from aorta (P = .15), LITA (P = .4), saphenous vein grafts (P = .13), and in situ RITAs. However, RITAs grafted to the left anterior descending coronary artery had fewer occlusions (P < .001), with patency similar to LITAs. CONCLUSIONS: Among patients with bilateral ITA grafting requiring interval coronary angiography, long-term RITA patency was high and independent of its inflow configuration. Therefore, priority should be a RITA configuration optimizing its reach to important coronary targets, including the left anterior descending coronary artery.

Retrograde Pulmonary Embolectomy for Acute Pulmonary Embolism: A Simplified Technique.

Surgical embolectomy in acute pulmonary embolism is usually reserved for patients with massive pulmonary embolism presenting with cardiogenic shock, or for whom thrombolysis is absolutely contraindicated or has failed. Incomplete removal of thrombotic material lodged in the distal pulmonary arterial bed is considered an important cause of persistent pulmonary hypertension. Retrograde pulmonary embolectomy is an adjunct to conventional pulmonary embolectomy, resulting in more complete embolectomy, specifically of material lodged in the distal pulmonary arterial bed. We describe our simplified technique of retrograde pulmonary embolectomy as a safe adjunct to conventional pulmonary embolectomy.

The axial continuous-flow blood pump: Bench evaluation of changes in flow associated with changes of inflow cannula angle.

BACKGROUND: Changes in the geometry of the HeartMate II (HMII) inflow cannula have been implicated in device thrombosis post-implant. The purpose of this in vitro study was to evaluate what effects changing the angle of the cannula in relation to the pump may have on pump flow and arterial pressure, under simulated inflow conditions. METHODS: The HMII with an inflow cannula was mounted on a mock loop consisting of a pulsatile pneumatic ventricle to simulate the native ventricle. The angles of the HMII in relation to the inflow cannula were adjusted by separate fixed gooseneck holders. A custom-made miniature steerable camera was introduced into a flexible portion of the HMII inflow cannula. Endoscopic views of various types of inflow cannula constriction (bending, squeezing, stretching and twisting) were recorded, and pump flow and systemic arterial pressure (AoP) were assessed during each simulation. RESULTS: Baseline mean pump flow (3.5 liters/min) and mean AoP (91.5 mm Hg) were unchanged by bending maximally in 2 different directions, twisting up to 30°, stretching (compression or extension), or occluding the inflow graft <90%. However, mean pump flow and mean AoP decreased substantially when the inflow graft became occluded by ≥90% by sliding or squeezing. CONCLUSIONS: "Less-than-critical" obstruction (what we define here as <90%) of the HMII inflow cannula did not reveal substantial changes in pump flow or AoP. Data suggest that a major alteration to inflow cannula geometry is required to achieve clinically relevant hemodynamic changes. These data confirm that minor changes in angulation of the inflow cannula have no impact on flow through the device.

Substernal Colonic Interposition After Previous Coronary Artery Bypass Graft in a Patient With a Patent Left Internal Thoracic Artery Graft: A Surgical Challenge.

Esophageal reconstruction by a substernal route with a colonic conduit after previous esophagectomy and end-cervical esophagostomy in the presence of a patent left internal thoracic artery graft to the left anterior descending coronary artery is a technically challenging procedure. In this case report, we describe a safe approach to this difficult problem. With proper planning and careful dissection, substernal esophageal reconstruction after previous sternotomy in patients with a patent left internal thoracic artery graft is feasible and can be safely performed.

Recurrent aortic aneurysms in Behçet disease.

The following is a case of a 22-year-old male with recurrent thoracic aneurysms with several constitutional symptoms, including gastrointestinal discomfort, irritable bowel syndrome, lactose intolerance, and a 2-week history of severe lower back pain. The patient underwent an initial thoracoabdominal repair of a visceral aneurysm followed by endovascular repair of a recurrent thoracic pseudoaneurysm. The etiology of the visceral aneurysm was initially hypothesized to be mycotic; however, further information revealed signs and symptoms consistent with the diagnostic criteria for Behçet disease (BD). We suggest that BD be considered in younger patients who present with an aortic aneurysm. Although open repair is the traditional approach for arterial lesions in BD, the role for endovascular intervention should be considered as it represents a surgical repair with a significant reduction in morbidity.