Ten-year outcomes after off-pump versus on-pump coronary artery bypass grafting: Insights from the Arterial Revascularization Trial.

OBJECTIVE: We performed a post hoc analysis of the Arterial Revascularization Trial to compare 10-year outcomes after off-pump versus on-pump surgery. METHODS: Among 3102 patients enrolled, 1252 (40% of total) and 1699 patients received off-pump and on-pump surgery (151 patients were excluded because of other reasons); 2792 patients (95%) completed 10-year follow-up. Propensity matching and mixed-effect Cox model were used to compare long-term outcomes. Interaction term analysis was used to determine whether bilateral internal thoracic artery grafting was a significant effect modifier. RESULTS: One thousand seventy-eight matched pairs were selected for comparison. A total of 27 patients (2.5%) in the off-pump group required conversion to on-pump surgery. The off-pump and on-pump groups received a similar number of grafts (3.2 ± 0.89 vs 3.1 ± 0.8; P = .88). At 10 years, when compared with on-pump, there was no significant difference in death (adjusted hazard ratio for off-pump, 1.1; 95% confidence interval, 0.84-1.4; P = .54) or the composite of death, myocardial infarction, stroke, and repeat revascularization (adjusted hazard ratio, 0.92; 95% confidence interval, 0.72-1.2; P = .47). However, off-pump surgery performed by low volume off-pump surgeons was associated with a significantly lower number of grafts, increased conversion rates, and increased cardiovascular death (hazard ratio, 2.39; 95% confidence interval, 1.28-4.47; P = .006) when compared with on-pump surgery performed by on-pump-only surgeons. CONCLUSIONS: The findings showed that in the Arterial Revascularization Trial, off-pump and on-pump techniques achieved comparable long-term outcomes. However, when off-pump surgery was performed by low-volume surgeons, it was associated with a lower number of grafts, increased conversion, and a higher risk of cardiovascular death.

Outcomes of mitral valve repair for chronic ischemic mitral regurgitation.

Mitral regurgitation is a frequent complication of ischemic heart disease. A retrospective study was performed on 127 patients with significant ischemic mitral regurgitation (regurgitant jet area > or =6.0 cm2 and/or vena contracta width > or =0.70 cm) who underwent elective mitral valve repair between January 2001 and October 2007. Concomitant myocardial revascularization was carried out in all except one patient, and left ventricular restoration in 8. All patients had ring annuloplasty, with release of posterior mitral leaflet tethering in 21, leaflet resection in 7, chordal transfer in 3, and chordal shortening in 2. There were 4 (3.1%) hospital deaths. Two patients underwent successful mitral valve replacement for repair failure in the immediate postoperative period, and one had an unsuccessful valve replacement at 3 months. During a mean follow-up of 19.65 +/- 13.21 months in 121 patients, 111 had trivial or no residual regurgitation, and 10 had mild regurgitation. Mitral valve repair for chronic ischemic mitral regurgitation is a reproducible technique with satisfactory early and mid-term outcomes and freedom from valve-related complications.

Off-pump coronary revascularization for left main coronary artery stenosis.

Experience of on- and off-pump coronary artery bypass in 379 patients with significant left main coronary artery stenosis was retrospectively reviewed. Beating-heart operations were performed on 219 patients between January 2001 and October 2007. Their results were compared with 160 who underwent revascularization under cardiopulmonary bypass during the same period. All patients had multivessel grafting via a median sternotomy. Both groups were comparable demographically. Off-pump patients received significantly fewer grafts per patient (3.21 +/- 0.86 vs 3.74 +/- 0.82). The use of moderate or high doses of inotropics (> 5 microg kg(-1) min(-1)) was more frequent in the on-pump group (44% vs 26%). Postoperative blood transfusion requirement was lower in off-pump patients, and fewer of them experienced worsening of preexisting renal insufficiency. There were 2 operative deaths in the on-pump group and 1 in the off-pump group. The off-pump procedure is safe and effective in patients with left main coronary artery disease.

Correction of anomalous drainage of right superior vena cava to left atrium.

A 2-year-old boy with cyanosis was found to have normal situs and looping with anomalous drainage of a right-sided superior vena cava to the left atrium, and intact interatrial septum in association with anomalous drainage of the left pulmonary veins to the right superior vena cava. He underwent successful surgical repair of this rare congenital malformation.

Postinfarction ventricular septal defect: patch repair with infarct exclusion.

Postinfarction rupture of the interventricular septum is usually fatal without prompt surgical intervention. Repair of postinfarction ventricular septal rupture by an endocardial patch technique with infarct exclusion is associated with less morbidity and mortality. The results of this repair in 22 consecutive patients were analyzed retrospectively. After myocardial infarction, 16 patients were operated on within 7 days, 3 at 8-21 days, and 3 at 3-6 weeks. 2D-echocardiography, color Doppler studies and coronary angiography were performed in all patients prior to surgery. The mean age of the patients was 57.46 +/- 5.31 years and 20 were male; 15 were in cardiogenic shock or congestive heart failure at the time of operation. There were 5 (22.7%) operative deaths. Postoperative complications included low cardiac output, renal failure and respiratory failure. Preoperative cardiogenic shock, severe right ventricular dysfunction, residual ventricular septal defect, and preoperative renal failure were predictors of operative mortality. There were 2 late deaths. A rapid diagnosis, aggressive medical management and prompt surgical intervention are required to optimize survival and recovery in patients who present with septal rupture complicating myocardial infarction.

Multinodular goiter compressing the trachea following open heart surgery.

Acute hemorrhage into an adenomatous goiter following cardiac surgery is a rare cause of acute upper airway obstruction. We report an unusual presentation of respiratory distress in a patient with goiter recovering from open heart surgery, which was successfully treated by left hemithyroidectomy. A mandatory evaluation of the upper trachea in patients with long-standing benign goiter is recommended prior to cardiac surgery.