Endoscopic versus open radial artery harvesting for coronary artery bypass grafting.

AIM: The radial artery has become the artery of choice after the internal thoracic artery for coronary artery bypass grafting (CABG). This study compares wound healing and arm complications after endoscopic versus open radial artery harvesting for CABG. METHODS: From January 2002 to July 2004, 509 patients underwent CABG in which a radial artery conduit was used. Thirty-nine had endoscopic and 470 had conventional open radial artery harvesting. A propensity score was used to obtain 1:3 matching of all endoscopic to 117 open-harvesting patients. Postoperative wound healing using the Hollander scale, local neurologic deficits, wound infection, and pain scores were compared. RESULTS: Wound healing: 34 of 39 endoscopic wounds exhibited a perfect Hollander score versus 339 of 470 open-harvest wounds (P=0.01). Wound appearance in particular was better than for open harvesting (P=0.004), with no abnormal step-off borders, irregular contours, or abnormal scar width observed. Neurologic deficits. Three incomplete neurologic deficits were observed after open harvesting (two being distal sensitivity localized in the interspace between the first and second metacarpals); one complete neurologic deficit occurred after endoscopic harvesting, but improved remarkably prior to hospital discharge. Wound infection. Occurrence of wound infection was similar in the two groups (P=0.7), although infection was more severe with open harvesting. Pain: pain score was lower (P=0.006) with endoscopic harvesting. CONCLUSION: Compared with conventional open harvesting, endoscopic radial artery harvesting was associated with better wound appearance and less pain. Occurrence of neurologic deficits and wound infection was infrequent in both groups.

Aortic valve stenosis and regurgitation: an overview of management.

UNLABELLED: There are few cardiovascular disease entities that have as an impressive contribution to improved quality and duration of life as aortic valve disease correction. Although aortic valve stenosis is fairly common, particularly in elderly patients, between one third and two thirds go untreated, despite operative survival rates with the minimal invasive J incision approach of 99%. For those patients with high risk co-morbidity or technical inoperable reasons, the percutaneous transfemoral or transapical approaches are now available with good initial RESULTS: For younger patients with tricuspid valves or bicuspid valves and aortic regurgitation, aortic valve repair should be the first choice procedure and with careful selection of the appropriate approach based on analysis of the patients CLASS (Commissure, Leaflet, Annulus, Sinotubular junction, and Sinuses) anatomy. Excellent results can be obtained with better than 90% freedom from reoperation at 10 years. The scope of procedures for aortic valve disease has increased markedly over the last 10 years and patients and cardiovascular physicians need to be aware of these newer options.

Paralysis after aortic surgery: in search of lost cord function.

During the early 1980s, the rate of paralysis after aortic surgery was as high as 41% in patients for the most complex thoracoabdominal aortic operations. After comparing human and chacma baboon (papio ursinus) spinal cord vascular anatomy, an animal model was established to study the pathophysiology of aortic cross-clamping and the aetiology of the paralysis. Techniques, including motor evoked responses for monitoring spinal cord function, were developed that were tried in humans and later culminated in prospective and randomized studies. These established that the following were protective: combining cerebrospinal fluid with intrathecal papaverine; cooling systemically to moderate or profound hypothermia; minimizing intercostal ischaemia time; using a sequential segmental repair approach; re-attaching all patent and segmental intercostal arteries below T8 for descending thoracic aortic repair and from T6 to L2 for thoracoabdominal repairs; continuing cerebrospinal fluid drainage for at least two days and maintaining patients hypertensive after surgery. The net result has been that, in two of our recent series, the risk of permanent paralysis has been reduced to between 3.1% and 3.8%.

Management of right-sided aortic arch aneurysms.

Specific technical problems are associated with the management of patients who have either of the two types of right-sided arches and aneurysms of the aortic arch and descending aorta. Two different approaches to addressing these problems, depending on the predominant congenital vascular anatomy, are presented.

Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations.

BACKGROUND: To determine the optimal method of brain protection during deep hypothermic circulatory arrest (DHCA) for arch repair. METHODS: Of 139 potential aortic arch repairs (denominator), we randomized 30 patients to either DHCA alone (n = 10), DHCA plus retrograde brain perfusion (RBP) (n = 10), or antegrade perfusion (ANTE) (n = 10); a further 5 coronary bypass (CAB) patients were controls. Fifty-one neurocognitive subscores were obtained for each patient at each of four intervals: preoperatively, 3 to 6 days postoperatively, 2 to 3 weeks postoperatively, and 6 months postoperatively. Intraoperative and postoperative S-100 blood levels and electroencephalograms were also obtained. RESULTS: For the denominator, the 30-day and hospital survival rate was 97.8% (136 of 139) and the stroke rate 2.8% (4 of 139). For the randomized patients, the survival rate was 100% and no patient suffered a stroke or seizure. Circulatory arrest (CA) times were not different (DHCA: RBP:ANTE) for 11 total arch repairs (including 6 elephant trunk; mean, 41.4 minutes; standard deviation, 15). Hemiarch repairs (n = 17) were quickest with DHCA (mean 10.0 minutes; standard deviation, 3.6; p = 0.011) and longest with ANTE (mean 23.8 minutes; standard deviation, 10.28; p = 0.004). Of the patients, 96% had clinical neurocognitive impairment at 3 to 6 days, but by 2 to 3 weeks only 9% had a residual new deficit (1 DHCA, 1 RBP, 1 ANTE), and by 6 months these 3 patients had recovered. Comparison of postoperative mean scores showed the DHCA group did better than RBP patients in 5 of 7 significantly different (p < 0.05) scores and versus 9 of 9 ANTE patients. There were no S-100 level differences between CA groups, but levels were significantly higher versus the CAB controls, particularly at the end of bypass (p < 0.0001); however, these may have been influenced by other variables such as greater pump time, cardiotomy use, and postoperative autotransfusion. Circulatory arrest (p = 0.01) and pump time (p = 0.057) correlated with peak S-100 levels. CONCLUSIONS: The results of hypothermic arrest have improved; however, there is no neurocognitive advantage with RBP or ANTE. Nevertheless, retrograde brain perfusion may, in a larger study, potentially reduce the risk of strokes related to embolic material. S-100 levels may be artificial. In patients with severe atheroma or high risk for embolic strokes, we use a combination of retrograde and antegrade perfusion on a selective basis.

Hypothermic arrest for descending aortic rupture in reoperative patients.

Establishing hypothermic bypass for repair of descending thoracic aortic rupture in reoperative patients presents unique challenges for the operative team. A higher risk of stroke, embolization, and malperfusion further increases overall morbidity and mortality. Traditional femoral arterial cannulation may not be the optimal route for bypass for these patients. We report two reoperative cases using the right subclavian artery for arterial inflow to avoid these problems.

Elephant trunk anastomosis between left carotid and subclavian arteries for aneurysmal distal aortic arch.

There is an increased risk of rupture with attempting a distal anastomosis when the distal aortic arch exceeds 5 to 6 cm. To circumvent this problem, we describe performing the anastomosis between the left common carotid and the left subclavian arteries and, at the second-stage operation, interposing a tube graft between the left subclavian artery and the descending aortic tube graft.

Minimal access aortic surgery including re-operations.

OBJECTIVES: Safety and benefits of minimal access ascending aorta and aortic arch surgery, including for re-operations has not been reported. METHODS: Fifty-four patients undergoing minimal access operations were evaluated. Of the 54 patients, valve replacements were performed in 76% (41 patients) (including composite valve grafts), and re-operations in 33% (18 patients). Composite valve grafts were used in 28% (15 patients) patients, and elephant trunk type procedures in 6% (three patients). RESULTS: The survival rate was 96% (52 patients), stroke 3.7% (two patients), and neurocognitive deficit 1.8% (one patient). The circulatory arrest time was 20 min (SD 17), aortic crossclamp time 91 min (SD 45) and cardiopulmonary bypass time 132 min (SD 59). Intraoperative homologous blood transfusion was a mean of 1.3 units (SD 2.3). ICU and postoperative stay were 1.8 days (SD 1.9) and 6.7 days (SD 3.7), respectively. No patient died after re-operation, although one patient had a stroke. CONCLUSIONS: Minimal access aortic surgery does not appear to carry a greater risk and, although more demanding technically, is associated with a reasonable ICU and hospital stay. For re-operations, we particularly recommend the technique.

Carbon dioxide field flooding techniques for open heart surgery: monitoring and minimizing potential adverse effects.

The use of carbon dioxide for displacement of air in cardiac surgery can have potential adverse effects on blood gas strategies. Presented is a method of monitoring carbon dioxide in the cardiopulmonary bypass circuit and limiting the potential for severe hypercarbia during cardiopulmonary bypass.

Management of aortic valve disease during aortic surgery.

BACKGROUND: Alternative management strategies for aortic valve disease and aortic operation include valve preservation and aortic repair (VPR), composite valve graft (CVG), or separate valve and aortic repair (SVR). We evaluated these approaches. METHODS: Of 250 ascending/arch operations, 151 patients had aortic valvular disease and dissection (n = 56, 37%) or aneurysms operated between November 1990 and January 1998. Sixty-seven patients underwent CVG insertion, 50 SVR, 13 VPR, and 21 only aortic repair alone (RA). Sixty (40%) patients also had aortic arch repairs and 53 (35%) coronary artery bypasses. RESULTS: The early 30-day survival and stroke rates were 99% (150 of 151) and 0% (0 of 151), respectively: CVG 100% (67 of 67), 0%; VPR 100% (13 of 13), 0%; SVR 98% (49 of 50), 0%; RA 100% (21 of 21), 0% (p = not significant [NS]). On late follow-up of all patients (5 to 92 months; 96% complete 1998), 3 CVG, 2 VPR, 6 SVR, and 0 RA patients died with respective 5-year Kaplan-Meier survival rates of 88.4%, 70%, 69%, and 100% (p = 0.07, log-rank test). The respective linear rates for stroke were 0%, 5.5% (n = 1), 0%, and 0%; for hemorrhage were 0%, 0%, 0%, and 0%; and for endocarditis were 2.2% (n = 3), 0%, 0%, and 0% (p = NS). There were 11 late deaths and no patient required reoperation or ruptured the ascending aorta or the aortic arch. CONCLUSIONS: With careful selection of the appropriate method excellent early and late results can be achieved.

Readmission after cardiac operations: prevalence, patterns, and predisposing factors.

OBJECTIVES: This study was undertaken (1) to determine the prevalence of hospital readmission within 1 month of discharge after cardiac operations, (2) to categorize diagnoses responsible for readmission, and (3) to examine predischarge patient factors that influenced readmission. METHODS: Data at 1 month after discharge were obtained for 1665 (98.4%) of 1692 patients who underwent cardiac operations between January 1996 and July 1998. RESULTS: Two hundred twenty-five patients (13.5%) were readmitted to a hospital within a 1-month period after discharge. Forty-eight percent of readmissions were to other hospitals. The most common readmission problems were congestive heart failure (15.6%), atrial fibrillation (12.9%), chest pain (12.0%), wound problems (10.2%), and gastrointestinal problems (8.0%). Hospital discharge on or before the fifth postoperative day was associated with a lower prevalence of subsequent readmission. The independent predictors of a readmission for congestive heart failure were postoperative stay longer than 5 days, diabetes, New York Heart Association functional class IV, preoperative congestive heart failure, total blood product use, the need for postoperative inotropes, body mass index greater than 28 kg/m(2), and reoperation for bleeding. CONCLUSIONS: The prevalence of rehospitalization during the first month after discharge is not trivial. Other than postoperative atrial fibrillation, readmission is probably the single most likely adverse event to befall a patient in the early postoperative period. Patients who are discharged early do not appear to be at increased risk. Patterns in readmission diagnoses suggest opportunities for preventive strategies.

An approach to spinal cord protection during descending or thoracoabdominal aortic repairs.

BACKGROUND: During the past few years, after much research, progress has been made in reducing the risk of spinal cord injury after descending or thoracoabdominal aortic repairs. METHODS: Based on that research I describe a method to reduce the risk of spinal cord injury. RESULTS: Our data show that with this technique, less than 5% of our patients had a permanent injury whereby they are unable to walk. CONCLUSION: The use of intrathecal papaverine, cerebrospinal fluid drainage, hypothermia, and reimplantation of intercostal arteries from below T6 to and including L1 are recommended.

How to obtain hemostasis after aortic surgery.

BACKGROUND: The establishment of hemostasis without the excessive transfusion of homologous blood and blood products is critical to successful aortic surgery. METHODS AND RESULTS: By using preoperative autologous blood donation and intraoperative blood conservation measures, 85% of patients can undergo aortic surgical procedures without homologous blood or product transfusions, and almost three-quarters of patients will still not have required homologous transfusions by the time of discharge. In contrast, three-quarters of those patients who cannot donate blood preoperatively will require homologous blood transfusions. CONCLUSIONS: The strategy described is safe: our overall survival rate for 204 patients has been 98%, with a 1% incidence of stroke.

Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques.

BACKGROUND: The modern imaging techniques of transesophageal echocardiography, CT, and MRI are reported to have up to 100% sensitivity in detecting the classic class of aortic dissection; however, anecdotal reports of patient deaths from a missed diagnosis of subtle classes of variants are increasingly being noted. METHODS AND RESULTS: In a series of 181 consecutive patients who had ascending or aortic arch repairs, 9 patients (5%) had subtle aortic dissection not diagnosed preoperatively. All preoperative studies in patients with missed aortic dissection were reviewed in detail. All 9 patients (2 with Marfan syndrome, 1 with Takayasu's disease) with undiagnosed aortic dissection had undergone >/=3 imaging techniques, with the finding of ascending aortic dilatation (4.7 to 9 cm) in all 9 and significant aortic valve regurgitation in 7. In 6 patients, an eccentric ascending aortic bulge was present but not diagnostic of aortic dissection on aortography. At operation, aortic dissection tears were limited in extent and involved the intima without extensive undermining of the intima or an intimal "flap." Eight had composite valve grafts inserted, and all survived. Of the larger series of 181 patients, 98% (179 of 181) were 30-day survivors. CONCLUSIONS: In patients with suspected aortic dissection not proven by modern noninvasive imaging techniques, further study should be performed, including multiple views of the ascending aorta by aortography. If patients have an ascending aneurysm, particularly if eccentric on aortography and associated with aortic valve regurgitation, an urgent surgical repair should be considered, with excellent results expected.

Chronic traumatic aortic pseudoaneurysm: resolution with observation.

Immediate operative repair is the most commonly recommended treatment for traumatic aortic ruptures, regardless of age or size of the lesion. We report a patient who presented with a large chronic aortic pseudoaneurysm and has been thus far managed nonoperatively with shrinkage of his lesion and no symptoms.

Coronary-subclavian steal associated with severe aortic stenosis treated with combined percutaneous stenting and minimally invasive aortic valve replacement.

We describe coronary-subclavian steal restricting flow to the left internal mammary artery (LIMA) associated with critical aortic stenosis treated with combined percutaneous transluminal stenting and minimally invasive aortic valve replacement (AVR). An 86-year-old patient had coronary artery bypass graft placement (CABG) seven years prior with the LIMA anastomosed to the left anterior descending coronary artery (LAD). At the time of CABG, the patient had mild aortic stenosis and normal left ventricular function. By the time of re-presentation with refractory angina and heart failure, the patient had developed critical aortic stenosis. Because repeat CABG with median sternotomy risked damaging the LIMA, pre-operative revascularization was planned to minimize the likelihood of peri-operative ischemia. Stenting of the subclavian artery was performed prior to minimally invasive AVR.

Expanding surgical options using minimally invasive techniques for cardio-aortic and aortic procedures.

In an effort to minimize the morbidity and mortality of open cardio-aortic and aortic operations, which are ranked among the most extensive procedures, surgeons are attempting to use smaller minimal-access incisions, less-invasive open procedures, or more distal access sites to place aortic stented grafts by intraluminal closed methods. We review the latest trends in this rapidly evolving new field of minimally invasive surgery.