Less invasive multivessel coronary artery bypass grafting: now is the time.

PURPOSE OF REVIEW: Less invasive multivessel coronary artery bypass grafting techniques have seen a progressive evolution over the last two decades. In their current state, they are easily reproduced and applicable to most patients requiring multivessel revascularization. The purpose of this review is to highlight their importance among a spectrum of evolving therapies and the accruing evidence in their favour. RECENT FINDINGS: The first large dual center experience with minimally invasive coronary artery bypass grafting (MICS CABG) demonstrated the feasibility of performing multivessel surgical revascularization without the need for sternotomy or cardiopulmonary bypass. Subsequent angiographic studies to assess graft patency showed excellent early results. Studies comparing MICS CABG to conventional CABG demonstrate faster recovery while reducing hospitalization and cost. SUMMARY: Multivessel less invasive coronary artery bypass grafting is basically limited to two procedures, MICS CABG and robotically assisted totally endoscopic CABG (TECAB). MICS CABG has evolved as a procedure that preserves the safety and efficacy of conventional CABG while avoiding the associated morbidity. It is reproducible, versatile and holds promise as the procedure of choice for multivessel coronary revascularization in the future. TECAB is likely the pinnacle of minimally invasive coronary surgery, the growth of which is hindered by widespread acceptance and industry involvement.

Clinical outcomes and hemodynamic performance of Dafodil™ aortic and mitral pericardial bioprosthesis: 1-year results from Dafodil-1 first-in-human trial.

BACKGROUND: Bioprosthesis has been increasingly implanted for the treatment of transvalvular disease across the world. A new Dafodil™ pericardial bioprosthesis (Meril Life Sciences Pvt. Ltd., India) recently approved by Conformité Européenne (CE) is a tri-leaflet, stented, bovine valve. The purpose of Dafodil-1 first-in-human trial was to evaluate clinical safety and performance (including hemodynamic parameters) of the Dafodil pericardial bioprosthesis in patients who underwent aortic or mitral valve replacement. METHODS: This prospective, multicenter clinical trial enrolled 60 patients (Aortic: 30 patients; Mitral: 30 patients) from seven sites across India. Safety endpoints were early (≤30 days) and late (> 30 days) mortality and valve-related morbidity. The performance endpoints were hemodynamic performance, improvement in NYHA functional class, and change in the quality of life using SF-12v1 health survey. RESULTS: From July 2017 to July 2018, 60 patients underwent implantation of the Dafodil pericardial bioprosthesis. Post-operatively, NYHA functional class significantly improved in all the patients (Aortic: 90% NYHA class-I and 10% NYHA class-II; Mitral: 96.55% NYHA class-I and 3.45% NYHA class-II; P < 0.001). There was no death in aortic valve replacement patients till 12-month. In mitral valve replacement patients, early mortalities occurred in three patients, and late mortality occurred in one patient; none of these were valve-related. Freedom from all-cause mortality reported was 93.33% at 12-month. Mean aortic pressure gradient decreased from 52.71 ± 24.47 mmHg [with 0.89 ± 0.70 cm2 effective orifice area (EOA)] pre-operatively to 14.49 ± 6.58 mmHg (EOA: 1.85 ± 0.27 cm2) at 12-month. Overall, the mitral mean pressure gradient and EOA were 4.41 ± 1.69 mmHg and 2.67 ± 0.48 cm2, respectively, at 12-month. Significant improvement (P < 0.05) in the patients' quality of life was reported at all follow-ups. CONCLUSIONS: The clinical safety and performance of the Dafodil pericardial bioprosthesis were favourable at 12-month. Moreover, a study with a larger patient population and longer follow-up is warranted to further assess the device. TRIAL REGISTRATION: Dafodil-1 trial has been prospectively registered on 10/07/2017 under Clinical Trial Registry-India (http://www.ctri.nic.in). (Registration number: CTRI/2017/07/009008).

Minimally Invasive coronary surgery compared to STernotomy coronary artery bypass grafting: The MIST trial.

RATIONALE: Minimally invasive cardiac surgery has emerged as a safe alternative to standard cardiac surgery. Minimally invasive coronary surgery (MICS CABG) was developed to allow adequate exposure and complete revascularization in CABG from a small thoracotomy incision without cardiopulmonary bypass. Multiple studies have reported significant shorter length of hospital stay and earlier postoperative physical recovery for MICS CABG patients when compared to sternotomy CABG patients. However, there have been no convincing clinical trials that demonstrate improvement in post-operative quality of life for patients who undergo MICS CABG. STUDY DESIGN: The Minimally Invasive Coronary Surgery compared to Sternotomy Coronary Artery Bypass Grafting (MIST) trial is a multi-centered, prospective randomized controlled trial that compares the quality of life and recovery in the early post-operative period between patients undergoing MICS CABG versus patients undergoing sternotomy CABG. Patients will be randomized either to the MICS CABG group or the sternotomy CABG group, and the target enrollment is 88 patients per group. The primary outcome is quality of life assessment performed by SF-36 questionnaire at 1 month. CONCLUSION: The MIST trial is the first prospective study that compares the quality of life between MICS CABG and sternotomy CABG patients. The results of this trial may enhance the procedural desirability of MICS CABG by patients and provide an incentive for surgeons and institutions to increase the availability of MICS CABG in suitable patients.

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario.

PURPOSE: Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS: A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS: The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS: Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.

Anticoagulation Management in Patients with Valve Replacement.

Background: Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. The aim of this review is to assess the role of anticoagulation therapy in the management of valve replacement patients. Methodology: Literature from PubMed, Embase, Medline and Google Scholar were searched using the terms "valvular heart disease", "anticoagulant", "mechanical heart valve", "bioprosthesis", "bridging", "Vitamin K antagonist (VKA)", and "acenocoumarol". A committee comprising leading cardiothoracic surgeons from India was convened to review the literature and suggest key practice points. Results: Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. A paramount risk of thromboembolic events is observed during the first three months after surgery for both mechanical and bioprosthetic devices. The VKA therapy with individualized target international normalized ratio (INR) is recommended in patients after prosthetic valve replacement. Therapies for the management of prosthetic valve complications should be based on the type of complications. Special care is mandated in distinguished individuals and those with various co-morbidities. Conclusion: In patients with prosthetic valve replacement, anticoagulant therapy with VKA seems to be an effective option. The role for non-VKA oral anticoagulants in the setting of prosthetic valve replacement has yet to be established. Furthermore, whether the novel oral anticoagulants are safe and efficacious in patients after placement of a bioprosthetic valve remains unanswered.

Aortic valve replacement in a patient with systemic lupus erythematosus.

Valvular heart disease in systemic lupus erythematosus (SLE) is associated with substantial morbidity and mortality. Current therapy includes symptomatic measures and valve replacement. SLE can present major challenges because of accrued organ damage, coagulation defects and complex management regimes. The peri-operative goals are to maintain strict asepsis, avoid use of nephrotoxic drugs and thereby renal insult, and to promote early ambulation post-operatively.

Outcomes of coronary artery bypass grafting and reduction annuloplasty for functional ischemic mitral regurgitation: a prospective multicenter study (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve).

OBJECTIVE: Functional ischemic mitral regurgitation is a complication of ventricular remodeling; standard therapy is reduction annuloplasty and coronary artery bypass grafting. Unfortunately, outcomes are retrospective and contradictory. We report a multicenter study that documents the outcomes of reduction annuloplasty for functional ischemic mitral regurgitation. METHODS: Twenty-one centers randomized 75 patients to the coronary artery bypass grafting + reduction annuloplasty subgroup that was the control arm of the Randomized Evaluation of a Surgical Treatment for Off-pump Repair of the Mitral Valve trial. Entry criteria included patients requiring revascularization, patients with severe or symptomatic moderate functional ischemic mitral regurgitation, an ejection fraction 25% or greater, a left ventricular end-diastolic dimension 7.0 cm or less, and more than 30 days since acute myocardial infarction. All echocardiograms were independently scored by a core laboratory. Reduction annuloplasty was achieved by device annuloplasty. Two patients underwent immediate intraoperative conversion to a valve replacement because reduction annuloplasty was unable to correct mitral regurgitation; as-treated results are presented. RESULTS: Thirty-day mortality was 4.1% (3/73). Patients received an average of 2.8 bypass grafts. Mean follow-up was 24.6 months. Mitral regurgitation was reduced from 2.6 ± 0.8 preoperatively to 0.3 ± 0.6 at 2 years. Freedom from death or valve reoperation was 78% ± 5% at 2 years. There was significant improvement in ejection fraction and New York Heart Association class with reduction of left ventricular end-diastolic dimension. Cox regression analyses suggested that increasing age (P = .001; hazard ratio, 1.16 per year; 95% confidence interval, 1.06-1.26) and renal disease (P = .018; hazard ratio, 3.48; 95% confidence interval, 1.25-9.72) were associated with decreased survival. CONCLUSIONS: Coronary artery bypass grafting + reduction annuloplasty for functional ischemic mitral regurgitation predictably reduces mitral regurgitation and relieves symptoms. This treatment of moderate to severe mitral regurgitation is associated with improved indices of ventricular function, improved New York Heart Association class, and excellent freedom from recurrent mitral insufficiency. Although long-term prognosis remains guarded, this multicenter study delineates the intermediate-term benefits of such an approach.

Outcomes of the RESTOR-MV Trial (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve).

OBJECTIVES: we sought to determine whether patients with functional mitral regurgitation (FMR) would benefit from ventricular reshaping by the Coapsys device (Myocor, Inc., Maple Grove, Minnesota). BACKGROUND: FMR occurs when ventricular remodeling impairs valve function. Coapsys is a ventricular shape change device placed without cardiopulmonary bypass to reduce FMR. It compresses the mitral annulus and reshapes the ventricle. We hypothesized that Coapsys for FMR would improve clinical outcomes compared with standard therapies. METHODS: RESTOR-MV (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve) was a randomized, prospective, multicenter study of patients with FMR and coronary disease with core laboratory analysis. After enrollment, patients were stratified to the standard indicated surgery: either coronary artery bypass graft alone or coronary artery bypass graft with mitral valve repair. In each stratum, randomization was to either control (indicated surgery) or treatment (coronary artery bypass graft with Coapsys ventricular reshaping). RESULTS: the study was terminated when the sponsor failed to secure ongoing funding; 165 patients were randomized. Control and Coapsys both produced decreases in left ventricular (LV) end-diastolic dimension and MR at 2 years (p < 0.001); Coapsys provided a greater decrease in LV end-diastolic dimension (p = 0.021). Control had lower MR grades during follow-up (p = 0.01). Coapsys showed a survival advantage compared with control at 2 years (87% vs. 77%) (hazard ratio: 0.421; 95% confidence interval: 0.200 to 0.886; stratified log-rank test; p = 0.038). Complication-free survival (including death, stroke, myocardial infarction, and valve reoperation) was significantly greater with Coapsys at 2 years (85% vs. 71%) (hazard ratio: 0.372; 95% confidence interval: 0.185 to 0.749; adjusted log-rank test; p = 0.019). CONCLUSIONS: analysis of RESTOR-MV indicates that patients with FMR requiring revascularization treated with ventricular reshaping rather than standard surgery had improved survival and a significant decrease in major adverse outcomes. This trial validates the concept of the ventricular reshaping strategy in this subset of patients with heart failure. (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve [RESTOR-MV]; NCT00120276).

Ten-year experience with single-vessel and multivessel reoperative off-pump coronary artery bypass grafting.

OBJECTIVE: Patients undergoing reoperative coronary artery bypass have increased mortality and morbidity compared with those undergoing primary coronary bypass. The experience in applying off-pump techniques to coronary reoperations is limited. In this article we report a 10-year experience using various techniques of reoperative off-pump coronary bypass. METHODS: Between January 1996 and December 2005, 332 patients underwent reoperative off-pump coronary artery bypass grafting. Data were collected regarding the preoperative, intraoperative, and postoperative clinical course of all patients. These were compared with similar data obtained from patients who had undergone conventional coronary reoperation during this period. RESULTS: Two hundred ninety-six (89.2%) male and 36 female patients underwent reoperative off-pump coronary artery bypass. Of these, 265 (79.8%) patients underwent multivessel bypass through a median sternotomy, an anterolateral thoracotomy was performed in 63 (19%) patients, and a posterolateral thoracotomy was performed in 4 (1.2%) patients. The early mortality for patients undergoing off-pump surgery was lower than for those undergoing conventional reoperations (3.3% vs 5.5%, P = .066). Those who had undergone off-pump reoperations had less need for prolonged ventilation or prolonged inotropic support and had shorter intensive care unit and hospital stays than patients who had undergone redo coronary artery bypass grafting. CONCLUSION: For many patients requiring coronary reoperations, off-pump techniques are safe and feasible. Complete revascularization was achieved in at least 75% of patients in an unselected population, with mortality and perioperative event rates that are comparable with those of conventionally performed coronary reoperations.

Robotically enhanced coronary artery bypass surgery.

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28-76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min(-1). Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.

Totally endoscopic coronary artery bypass surgery.

Robotically enhanced surgery is a fast-developing technique that allows totally endoscopic cardiac surgery on both the beating and arrested heart. Between December 2002 and May 2005, 13 patients underwent totally endoscopic coronary bypass using the da Vinci system; 11 operations were on a beating heart and 2 on arrested hearts. The mean time for internal mammary artery mobilization was 42 min. The time for left internal mammary artery-to-left anterior descending artery anastomosis was 20-36 min for totally endoscopic cases. In one patient, the right internal mammary artery was anastomosed to the diagonal artery. No patient required conversion to a median sternotomy. Mean intensive care unit stay was 1.2 days and mean hospital stay was 4.5 days. There was no hospital mortality. All 13 patients had coronary angiography at 3-month intervals, which showed 100% patency in 12 patients while one had 50% anastomotic narrowing for which coronary angioplasty was performed. Using robotic technology, completely endoscopic anastomosis is possible in patients with single-vessel disease. Use of robotics is now extended to achieve complete myocardial revascularization by harvesting both internal mammary arteries in addition to making a small thoracotomy for direct anastomosis.

Coapsys mitral annuloplasty for chronic functional ischemic mitral regurgitation: 1-year results.

BACKGROUND: Untreated functional ischemic mitral regurgitation (MR) leads to reduced survival in patients undergoing coronary artery bypass grafting (CABG). However, mitral repair or replacement increases mortality and morbidity over CABG alone. The Myocor Coapsys annuloplasty system potentially reduces these risks by facilitating MR reduction on a beating heart without atriotomy. We present data from the first 11 patients completing 1-year follow-up of a total of 34 implanted patients. METHODS: Patients referred for CABG with preoperative grade 2 or greater ischemic functional MR were included in this study. Patients with structural valve defects or who demonstrated MR less than grade 2 after CABG, despite hemodynamic challenge, were intraoperatively excluded. Coapsys consists of two epicardial pads connected by a flexible chord implanted by passing the chord across the left ventricle with special instruments without cardiopulmonary bypass. The system was sized to reduce critical valve dimensions and MR. Serial clinical and echocardiographic data were collected out to 1 year. RESULTS: Mean age was 58.1 +/- 6.6 years and mean ejection fraction, 38.5% +/- 7.1%. From baseline to 1-year follow-up, effect on MR grade, MR jet area (cm2), and New York Heart Association class were, respectively, 2.9 +/- 0.5 to 1.1 +/- 0.8, 7.4 +/- 2.9 to 3.0 +/- 1.6, and 2.5 +/- 0.5 to 1.2 +/- 0.4 (all p < 0.05 versus baseline). During follow-up, there were no deaths, device failures, reemergence of grade 3 or 4 MR, heart failure readmission, or valve reoperations. CONCLUSIONS: The Coapsys annuloplasty system is effective in reducing functional ischemic MR and improving NYHA class. The initial data are encouraging and suggest that the device is safe and benefits are sustained at 1 year.

Port-access approach for cardiac surgical procedures: our experience in 776 patients.

BACKGROUND: Recent advances in minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery and atrial septal defect closure. The present study examines the feasibility, safety and efficacy of this technique. METHODS AND RESULTS: Between September 1997 and December 2004, 430 patients underwent mitral valve surgery through right anterolateral thoracotomy. The mitral valve was repaired in 62 patients, and 368 patients underwent mitral valve replacement. During same period, 336 patients underwent surgical closure of atrial septal defect. In all cases femoral artery and femoral venous cannulation was used for cardiopulmonary bypass. There was no approach-related limitation to surgical exposure, nor complication in cannulation of femoral vessels through the groin. Mean duration of cardiopulmonary bypass and cross-clamp time was 90 +/- 48 min and 51 +/- 29 min, respectively. Mean intubation time was 14.8 hours (range: 8-28 hours). Mean duration of intensive care andhospital stay was 26 hours (range: 18-38 hours) and 7 days (range: 5-17 days), respectively. In the atrial septal defect group, the mean cardiopulmonary bypass time and aortic cross-clamp time was 29 +/- 14 min and 19 +/- 8 min, respectively. Mean intensive care unit stay and mean hospital stay was 9.8 +/- 2.6 hours and 4.0 +/- 1.9 days, respectively. Hospital mortality was 0.46% (2/430) in the mitral valve group while there was no hospital mortality in atrial septal defect group. At a mean follow-up of 38.0 +/- 6.2 months there was one late death and two re-operations in the patients who underwent mitral valve surgery. CONCLUSIONS: Port-access approach is safe, offers faster recovery, cosmetic advantage, more patient satisfaction: it obviates the complications due to re-entry in redo cases and offers same efficacy as conventional operation. Furthermore, it is an excellent approach for mitral valve surgery in patients who had previous cardiac procedures. It has become our standard approach for repair of atrial septal defect and isolated mitral valve procedures.

Evolution of Off-Pump Coronary Artery Bypass Grafting over 15 Years: A Single-Institution Experience of 14,030 Cases.

BACKGROUND: : Off-pump coronary artery bypass grafting for multivessel disease is an important alternative to conventional myocardial revascularization using cardiopulmonary bypass. The development of exposure and stabilization techniques has made this surgery simple, safe, and routine. Experience with the technique, its evolution, the learning curve, and the pitfalls is presented. METHODS: : A retrospective analysis was made of 28,216 patients who underwent elective coronary artery bypass grafting over a 15-year period from January 1990 through December 2004. Isolated off-pump coronary artery bypass grafting was performed in 14,030 patients and on-pump coronary artery bypass grafting in 14,186 patients. The overall period was divided into 3 groups of 5 years each: group I (1990-1994), group II (1995-1999), and group III (2000-2004). Initially, off-pump coronary artery bypass grafting was performed selectively in high-risk patients (eg, atheromatous aorta, severe systemic impairment, chronic obstructive pulmonary disease, octogenarian). Recently (2000-2004), multivessel off-pump coronary artery bypass grafting has been performed electively in 96% to 98% of patients undergoing coronary artery bypass grafting. Patients' medical charts were reviewed for age, preoperative risk factors, operative findings, intraoperative conversion rate to cardiopulmonary bypass, postoperative complications, and length of hospital stay. RESULTS: : In the years 1990-1994 (group I), mostly high-risk cases and cases with left anterior descending coronary artery lesions were included for off-pump coronary artery surgery. In the years 1995-1999 (group II), patients with double and triple vessel disease presenting for coronary artery bypass surgery were accepted for off-pump surgery irrespective of preoperative risk factors. However, in the years 2000-2004 (group III), off-pump coronary artery bypass surgery was the first choice of approach for any patient presenting for coronary artery bypass surgery. The mean number of grafts was lower in off-pump cases than in on-pump cases in group I (2.0 ± 0.4 vs. 3.2 ± 0.80) and group II (2.6 ± 0.6 vs. 3.3 ± 0.4), whereas the mean number of grafts was higher in off-pump cases than in on-pump cases in group III (3.5 ± 0.2 vs. 3.4 ± 0.8). In groups I and II, the conversion to cardiopulmonary bypass was 5.2% and 5.9%, respectively. The conversion to cardiopulmonary bypass decreased to 1.7% in group III, which was statistically significant. Perioperative myocardial infarction was 5.2% in group I, 1.7% in group II, and 1.5% in group III. The difference between groups II and III was not statistically significant. Hospital mortality was higher in group I (5.2%) than in group II (1.2%) or III (1.1%). The difference between groups II and III was not statistically significant. Length of intensive care unit stay was 36 ± 8 hours in group I, 28 ± 7 hours in group II, and 20 ± 8 hours in group III. These differences were statistically significant. Length of postoperative hospital stay was 8 ± 2 days in group I, 7 ± 2 days in group II, and 5 ± 2 days in group III These differences were statistically significant. CONCLUSIONS: : As surgeons' experience matures, off-pump coronary artery bypass surgery permits total myocardial revascularization in virtually all patients with multivessel coronary artery disease. Despite a significant learning curve, evolution to routine off-pump coronary artery bypass with good patient outcomes can be achieved with careful patient selection during the "learning curve." The method is safe and reproducible, and patients benefit with shorter intensive care unit and hospital stays.

Transesophageal echocardiography in hypotensive post-coronary bypass patients.

The utility of transesophageal echocardiography in the evaluation of hypotension in the postoperative period after coronary artery bypass was assessed in 126 patients in the intensive care unit. There were 86 men and 40 women, with a mean age of 58.3 years. The indication for transesophageal echocardiography was hypotension refractory to conventional treatment. Valuable diagnostic information was obtained in 103 patients (82%). Based on the echocardiographic findings, 24 patients (19%) underwent urgent surgical intervention. The mean time required to obtain a diagnosis was 9.6 +/- 2.8 min. No significant complications were noted. Our experience suggests that transesophageal echocardiography is highly specific in diagnosing the cause of postoperative hypotension, thus preventing unnecessary surgical intervention and facilitating decision making in cardiac surgical emergencies.

Multimodality targeted approach in redo off-pump coronary artery bypass surgery.

Records of 86 patients who underwent off-pump redo coronary revascularization between December 1997 and December 2000, were analyzed. Approaches included median sternotomy (47), anterolateral thoracotomy for left anterior descending artery and diagonal targets (35), posterolateral thoracotomy for the obtuse marginal with proximal anastomosis on descending aorta (3), and a combined subxiphoid-anterior thoracotomy approach (1) for right gastroepiploic artery-to-left anterior descending artery anastomosis. The mean age was 61.82 years. There were 2 (2.3%) operative deaths. Complications included perioperative myocardial infarction in 4 patients and reexploration for bleeding in one. Blood transfusion was required in 12 patients. The mean length of hospital stay was 5 +/- 2 days. A multimodality targeted approach for off-pump redo coronary artery bypass offers a less invasive but safer method of myocardial revascularization, with decreased complications, lower blood product requirement, and early hospital discharge.

Off-pump multivessel coronary artery surgery in high-risk patients.

BACKGROUND: Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS: A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < or = 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS: The average number of grafts was 3.0 +/- 0.4 and 3.2 +/- 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 +/- 5 vs 24 +/- 6 hours, p < 0.001), mean blood loss (362 +/- 53 vs 580 +/- 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 +/- 8 hours) and hospital stay (6 +/- 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS: Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients.

Redo mitral valve surgery using the port-access system.

Redo mitral valve surgery is hazardous, hence we explored an alternative approach using a port-access system that avoids reentry. Between October 1997 and December 2000, 32 patients underwent mitral reoperation using the system. All patients had previous cardiac operations. This procedure consisted of a right anterolateral minithoracotomy and femorofemoral cannulation using special port-access instruments and endoaortic clamping in 24 patients or direct transthoracic sliding-rod aortic clamping in 8. The valve disease was of rheumatic etiology in 28 patients and degenerative in 4. The valve was replaced in 31 cases and a paravalvular leak after mitral valve replacement was closed in 1. In 2 cases, the tricuspid valve was repaired along with mitral valve replacement. Mean total operating time was 4.5 +/- 1.2 hours, cardiopulmonary bypass time 162 +/- 72 minutes, and aortic crossclamp time 62 +/- 21 minutes. There was no mortality, and mean stay in the intensive care unit was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. Postoperative blood transfusion was required in 12 patients. In view of the favorable results, we recommend using the port-access system as a standard approach for mitral reoperation.