Embedded Left Anterior Descending Artery During Coronary Bypass Operations: A 15-year Experience.

BACKGROUND: Revascularisation of the left anterior descending coronary artery (LAD) is the most important part of coronary artery bypass grafting (CABG) operations. We analysed the results of CABG in patients with embedded LADs compared to age and gender-matched controls. METHODS: Among 4,102 patients undergoing primary on-pump CABG from January, 1999, through April, 2014, 92 had embedded LADs. Direct dissection (n= 19) or retrograde probe technique (n= 73) was utilised to expose the LAD. Controls had epicardial courses of the LAD. A retrospective study was performed and follow-up information was obtained. RESULTS: Cross clamp and cardiopulmonary bypass times were longer (63.5 ± 8.5 vs. 46.6 ± 20, p<0.001; and 81.4 ± 21.4 vs. 60.1 ± 20.8, p<0.001, respectively) in the study group in which four patients had right ventricular injury (n = 3, direct dissection; n = 1, retrograde probe). The groups did not differ in terms of associated comorbidities, number of grafts, reoperation rate for bleeding, duration of intensive care unit stay, and duration of hospital stay. There were no hospital deaths in either group. Kaplan-Meier analysis showed similar survival rates postoperatively. CONCLUSIONS: In patients with embedded LADs, surgical outcomes following on-pump CABG compare favourably with the age- and gender-matched controls.

Mitral valve surgery using video-assisted right minithoracotomy and deep hypothermic perfusion in patients with previous cardiac operations.

BACKGROUND: Redo-sternotomy for mitral valve (MV) surgery may be complex and attendant complications can be avoided using anterolateral right thoracotomy, deep hypothermia (20°C, nasopharyngeal) with low flow cardiopulmonary perfusion. Video-assisted minithoracotomy technique is a further improvement. METHODS: We performed 20 consecutive MV operations in patients with previous cardiac surgery using video-assisted right minithoracotomy, femoro-femoral bypass, deep hypothermia, low flow cardiopulmonary bypass without aortic cross-clamping. The mean follow-up was 30 ± 17.8 mo. Data is presented as the mean ± standard deviation of the mean. RESULTS: There were 11 males and 9 females (age, 62.3 ± 12.1; ejection fraction 50.1 ± 11.2). Operations included MV replacement (n = 11), MV repair (n = 5), and MV re-replacement (n = 4). There were no hospital deaths, and the mean hospital stay was 8 ± 2.9 days. There were no postoperative strokes or need for mechanical circulatory support. The mean cardiopulmonary bypass time was 152 ± 28 minutes. Two patients (10%) required inotropic support beyond 24 hrs. All patients were free from inotropic support at 48 hours. The mean number of transfused red cell units was 2.8 ± 0.8 (range, 2 to 4). One patient died in another institution six months postoperatively following surgery for acute type III aortic dissection. At 30 ± 17.8 months follow-up all patients were found to be in NYHA Class I or II. CONCLUSIONS: Minimally invasive video-assisted MV surgery using deep hypothermia, low-flow cardiopulmonary bypass without aortic clamping can result in excellent clinical outcomes in patients with previous cardiac surgery via a median sternotomy. This technique offers reproducible results, good myocardial protection (as evidenced by the low rate of inotropic support that patients needed postoperatively), and low rates of complications.

Intimal intussusception in aortic dissection and coexisting coronary artery disease.

Intimal tear is rarely circumferential in aortic dissection. In such an instance, intimal intussusception may occur. This exposes the patient to the additional risk of severe aortic regurgitation, blockage of the left main coronary artery ostium, or both in proximal intimal intussusception in ascending aortic dissection. Here we present a 61-year-old patient with ascending aortic dissection, aortic regurgitation caused by an intussuscepted proximal intimal flap, and coexisting coronary artery disease. The presenting symptoms and electrocardiographic findings simulated an acute coronary syndrome. Among other diagnostic measures, only transesophageal echocardiography clearly defined the pathologic condition. The patient underwent a successful aortic root replacement and coronary artery bypass grafting.