Myocardial revascularization with the left internal thoracic artery Y graft configuration.

BACKGROUND: The proved long-term patency of the left internal thoracic artery (LITA) has made it the conduit of choice for myocardial revascularization. Maximal utilizable LITA length can be achieved by using a semiskeletonizing harvest technique. Expanded LITA use with sequential and Y graft techniques allows for a wider territory of myocardial revascularization. METHODS: A retrospective analysis of 30 patients undergoing coronary artery bypass surgery with a LITA-Y graft between December 1994 and November 1996 was performed. In selected patients the LITA was cut to length and anastomosed to the left anterior descending artery (LAD), with the redundant length of LITA used as a free graft to the lateral circumflex and diagonal systems. The proximal end of the free LITA was anastomosed to the in situ LITA to form the Y graft. Selection criteria included: a) minimal distal disease in the LAD and circumflex systems; and b) graftable circumflex branches proximal to the mid free wall of the left ventricle, allowing total revascularization of the left coronary system with the Y graft. RESULTS: Thirty patients (22 male, 8 female) underwent the LITA-Y graft procedure. There were no deaths or episodes of myocardial infarction. One patient required inotropic and intraaortic balloon pump support. Two patients with isolated coronary ostial stenosis developed recurrence of angina due to occlusion of the free limb of the LITA. CONCLUSIONS: In patients with suitable coronary artery anatomy, the LITA-Y graft can be successfully performed with good short-term outcome, but may be contraindicated in the management of isolated coronary ostial stenosis.

Myocardial revascularization with modified T-graft using bilateral internal thoracic arteries.

OBJECTIVE: By using a T-graft configuration, the myocardium may be completely revascularized with bilateral internal thoracic arteries. This study aimed to evaluate the perioperative morbidity and mortality in a single surgeon's early experience with a modified T-graft using bilateral internal thoracic arteries. METHODS: Between October 1994 to April 1997, 200 consecutive patients mostly selected per protocol, received a T-graft with bilateral internal thoracic arteries for stable angina pectoris (n = 157) or unstable angina pectoris (n = 43). The mean age of patients was 56 years (range of 36 to 78 years). There were 171 males and 29 females. Forty-three patients had diabetes. Concomitant procedures were performed in 8 patients. RESULTS: In 190 patients (95%), total arterial revascularization of the myocardium was achieved solely by the use of bilateral internal thoracic arteries in a T-graft configuration and the number of anastomoses per patient averaged 4.2. Ten patients (5%) received supplemental saphenous veins in addition to T-grafts for low cardiac output (n = 3), intraoperative regional ischaemia (n = 2), postoperative myocardial ischaemia (n = 2) and inadequate conduits (n = 3). The 30-day mortality was 0.5%. Perioperative myocardial infarct occurred in 2 patients (1.0%). Reasons encountered for early re-operation included bleeding (n = 7), sternal dehiscence (n = 5), suppurative sternitis (n = 3) and myocardial ischaemia (n = 2). Twelve patients received inotropes and intraaortic balloon counterpulsation was employed in 3 patients. CONCLUSION: When bilateral internal thoracic arteries were used in a T-graft configuration, total arterial revascularization of the myocardium was achieved with an acceptably low morbidity and mortality.

Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance.

We describe a technique of mini-thoracotomy to plicate the paralyzed hemidiaphragm with thoracoscopic assistance. Most of the hemidiaphragm can be plicated expeditiously under direct vision with light derived from a posterior thoracoscope placed in the auscultatory triangle. Videoscopic vision is employed only occasionally when the view of the posteromedial hemidiaphragm is obscured. Continuous suture traction can be easily applied through the mini-thoracotomy, thus maintaining suture tension and enabling maximal inversion of the elevated hemidiaphragm.

Lethal postoperative coronary artery spasm.

BACKGROUND: Coronary artery spasm in the immediate postoperative period after a coronary operation is recognized infrequently. Its severity is variable and manifestations unpredictable. The diagnosis is usually made by an awareness of the possibility and thereafter by exclusion of other causes of myocardial ischemia. An opportunity for a positive diagnosis is rarely available. METHODS: The case reports of 3 patients with similar presentations of ischemic heart disease and with severe manifestations of coronary artery spasm in the postoperative period are presented. RESULTS: All 3 patients were women aged 55 to 60 years. All had single-vessel coronary artery disease involving the left anterior descending artery and underwent a left internal mammary artery bypass graft. Severe manifestations of myocardial ischemia of abrupt onset developed approximately 7 hours postoperatively in each patient. One patient died of severe hemodynamic deterioration from which resuscitation was unsuccessful. Another sustained a large anterior myocardial infarction despite graft patency. The third patient was supported by an intraaortic balloon pump and made a full recovery. CONCLUSIONS: The early diagnosis of coronary artery spasm is achieved by an awareness of the condition. The institution of early appropriate management may prevent its consequences.

Tunnelling versus open harvest technique in obtaining venous conduits for coronary bypass surgery.

BACKGROUND: The tunnelling as opposed to the open harvest technique for harvesting long saphenous vein for coronary artery bypass procedures is a less frequently used technique as it requires more handling of the vein and this may induce trauma. This study aims to compare the degree of endothelial denudation and donor site morbidity between the two different harvest techniques. METHODS: Saphenous vein segments in 78 patients (45 in tunnelling versus 33 in open harvest group) undergoing coronary artery bypass procedures were examined by light microscopy and graded according to the extent of endothelial denudation varying from grade 1 (most preserved) to grade 6 (>90% endothelial denudation). Clinical parameters relating to donor site morbidity including leg wound pain and infection were also assessed. RESULTS: There was no statistical difference in the age, sex, macroscopic vein quality, length and time taken to harvest the veins between the two groups. The tunnelling technique always used thigh saphenous vein whereas nearly a third of veins harvested by the open harvest technique were lower leg veins (P=0.001). The tunnelling technique resulted in an endothelial score of 2.5 compared with 3.3 for the open harvest technique (P < 0.001). In addition, saphenous vein tunnelling resulted in significantly less leg wound pain (1.2 vs. 1.8, P=0.001), no leg wound infection (compared with 12.2% in open harvest group, P=0.02) and produced cosmetically more acceptable scars. Furthermore, length of hospital stay was significantly prolonged to 19.3 days in those with leg wound infection compared to 8.7 days in those without leg wound infection (P < 0.001). CONCLUSIONS: These results show that saphenous vein tunnelling is an attractive alternative to the open harvest technique in obtaining venous conduits for coronary artery bypass procedures.

Modified T graft for triple-vessel disease.

BACKGROUND: Arterial coronary bypass grafts are used in younger patients due to the limited long-term patency of saphenous vein grafts. Using both internal thoracic arteries in a T graft configuration allows complete myocardial revascularization without the need for alternative conduit. METHODS: A prospective analysis of 75 consecutive patients with triple-vessel disease who were aged less than 66 years and who had a left ventricular ejection fraction greater than 0.50 was performed from November 1994 to November 1995. Seventy-three patients underwent myocardial revascularization using a modified T graft technique using both internal thoracic arteries. Postoperative cardiac enzyme and electrocardiographic analyses were performed along with routine surgical and cardiologic review to March 1996. RESULTS: There were no deaths or perioperative myocardial infarcts, and there was no sternal dehiscence due to infection. Five patients had recurrent angina and underwent repeat angiography. Three were treated by single coronary artery angioplasty and 2 with medical therapy. CONCLUSIONS: A modified T graft revascularization of patients selected by the protocol used in this study is safe.

Retrosternal fat pad for prevention of suppurative sternitis.

An increased incidence of postoperative sternal infection has been reported after the use of bilateral internal mammary arteries for coronary artery grafting. In this series, a pedicled pericardial fat pad was mobilized to lie in the retrosternal space before the sternum was approximated. This technique was used in 101 consecutive patients who underwent coronary artery grafting using bilateral internal mammary arteries. Twenty-four percent of the patients were diabetic. No suppurative sternitis developed in any of these patients.

Retention of bioprosthetic valve annulus in mitral prosthetic replacement.

Mitral valve prosthetic replacement carries high mortality rates by modern standards, and mitral bioprostheses are particularly prone to degeneration. Bioprosthetic replacement may be technically difficult when there is calcification of the tissue ingrowth, strut incorporation, or valve-to-annulus size mismatch at the primary operation. A "valve-in-valve" technique is described where the mechanical prosthesis is implanted in the bioprosthetic annulus in order to avoid such difficulties. The results in the first eight patients are presented, showing post-operative Doppler-derived transvalvar mean gradients between 3.9 mmHg and 7.5 mmHg, and estimated valve areas between 1.9 cm2 and 3.5 cm2. All patients are alive at between 20 and 30 months (mean 23.6 months) after operation, they are without serious post-operative morbidity and are in functional class I or II (NYHA classification).

A 4-year experience with the Björk-Shiley Monostrut valve.

We reviewed 314 consecutive patients in whom a Björk-Shiley Monostrut aortic valve prosthesis was inserted by our cardiothoracic surgical unit from June 1982 through June 1986. The group comprised 220 males (70%) and 94 females (30%), with a mean age of 60 years (range, 5 to 83 years). Two hundred ninety-six patients (94%) received an aortic prosthesis alone, and the other 18 (6%) received both an aortic Monostrut valve and a Starr-Edwards mitral valve prosthesis. In each case, preoperative data were collected prospectively, and a questionnaire was sent at the time of follow-up. The median follow-up period was 23 months (range, 0 to 46 months); 6 (2%) of the patients were lost to follow-up. In the remaining 308 cases, there were 20 deaths (6.5%), 8 of which occurred within approximately 1 month after operation. There were no known instances of valve failure. One death occurred in the group that underwent double-valve replacement. Valve endocarditis accounted for 2 late deaths. With respect to preoperative dyspnea, 59 (19%) of the patients were in New York Heart Association functional Class I, 74 (24%) were in Class II, 138 (45%) were in Class III, and 37 (12%) were in Class IV. Postoperatively, there were 247 patients (80%) in Class I, 43 (14%) in Class II, 15 (5%) in Class III, and 3 (1%) in Class IV (p < 0.0001). All of the patients received postoperative anticoagulant therapy; 3.4% per year were subsequently readmitted for bleeding problems. Thromboembolic events necessitating hospitalization occurred in 3.0% of the patients per year. On the basis of these results, our early experience with the Björk-Shiley Monostrut valve in the aortic position has been satisfactory, with an acceptable rate of complications and no documented valve failures.

Malignant fibrous histiocytoma associated with a Dacron vascular prosthesis.

A case of malignant fibrous histiocytoma associated with a Dacron vascular prosthesis is presented. To our knowledge, only four such tumors have been previously recorded in the English-language literature despite extensive use of vascular prosthetic grafts over the last 30 years.

Gastric duplication in an adult.

Congenital alimentary duplications occur most commonly in relation to the ileum and are rare in the region of the stomach. A case of gastric duplication presenting in an adult and visualized on computed tomography is reported.