Off-pump coronary artery bypass grafting with skeletonized bilateral internal thoracic arteries in insulin-dependent diabetics.

BACKGROUND: We evaluated the effects of coronary artery bypass with off-pump skeletonized bilateral internal thoracic artery grafting in patients with insulin-dependent diabetes. METHODS: One hundred eighty-five consecutive patients with insulin-dependent diabetes who underwent isolated coronary artery bypass grafting with bilateral internal thoracic grafts were retrospectively compared according to surgical technique, ie, off-pump grafting with skeletonized internal thoracic artery (n = 162) or on-pump grafting with pedicled internal thoracic artery (n = 23). RESULTS: The on-pump group was younger (62.3 +/- 9.2 versus 69.9 +/- 8.5 years; p = 0.02) and had fewer distal anastomoses (3.5 +/- 1.0 versus 4.0 +/- 1.1; p = 0.02) than the off-pump group. No 30-day mortality occurred in either group. The incidence of deep sternal infection was significantly lower in the off-pump group than in the on-pump group (0.6% versus 13.0%; p = 0.01). The early angiographic results did not differ between the two groups. The median duration of follow-up was 3.4 years (range, 0.1 to 9.9 years). Rates of survival, freedom from cardiac mortality, and freedom from cardiac-related events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, repeat coronary artery bypass grafting, and congestive heart failure) did not differ between the two groups. Dialysis, peripheral vascular disease, ejection fraction less than 0.40, and age were independent risk factors of late death. CONCLUSIONS: Overall, our results support the surgical management of coronary artery bypass grafting in insulin-dependent diabetics using off-pump skeletonized bilateral internal thoracic artery grafting.

Oral sildenafil ameliorates impaired pulmonary circulation early after bidirectional cavopulmonary shunt.

We report a case of successful administration of oral sildenafil (ie, a phosphodiesterase-5 inhibitor) in an infant for impaired pulmonary circulation that caused early clinical deterioration after a bicavopulmonary shunt. The transpulmonary pressure gradient (ie, a clinical indicator of pulmonary circulation) was initially normalized by inhaled nitric oxide; however, an increase in transpulmonary pressure gradient and oxygen desaturation occurred after extubation and discontinuation of inhaled nitric oxide on postoperative day 1. Subsequent administration of oral sildenafil in stepwise doses resulted in normalization of transpulmonary pressure gradient and improved oxygen saturation with successful discontinuation of intravenous vasodilators. Our results suggest that oral sildenafil may be a potent adjunctive therapy for impaired postoperative pulmonary circulation after right heart bypass surgery.

Long-term results of bilateral internal thoracic artery grafting in dialysis patients.

BACKGROUND: We evaluated the perioperative and long-term results of bilateral internal thoracic artery grafting in dialysis patients. METHODS: One hundred one consecutive patients on chronic dialysis who underwent isolated coronary artery bypass grafting were retrospectively compared according to the surgical technique, bilateral internal thoracic artery (BITA) grafting (n = 76) or single internal thoracic artery (SITA) grafting (n = 25). RESULTS: Hospital mortality was 5.3% in the BITA group and 8.0% in the SITA group (p = not significant). The incidence of mediastinitis was not different (7.9% in the BITA group and 8.0% in the SITA group). The median duration of follow-up was 3.1 years (range, 0.1 to 10.9). Survival and freedom from cardiac mortality were not different between the two groups, but the BITA group had a trend toward better results. Freedom from cardiac events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, redo coronary artery bypass grafting, and congestive heart failure) was superior in the BITA group (p = 0.03). Calcification of the ascending aorta, peripheral vascular disease, insulin-dependent diabetes mellitis, and age were the independent risk factors of late death. CONCLUSIONS: Perioperative results of BITA grafting in dialysis patients were not different from the results of SITA grafting. However, the long-term results of BITA grafting in dialysis patients were better than the results of SITA grafting. Overall, our results support the continued use of BITA grafting in dialysis patients.

Early and midterm patency of the proximal anastomoses of saphenous vein grafts made with a Symmetry Aortic Connector System.

OBJECTIVE: The purpose of this study was to investigate (1) the early and midterm patency rates in saphenous vein grafts that were anastomosed with the Symmetry Aortic Connector System (St Jude Medical, Inc, St Paul, Minn) and (2) risk factors for graft occlusion. METHODS: Thirty-one patients underwent off-pump coronary artery bypass grafting for proximal saphenous vein graft anastomoses with the aortic connector system. Intraoperative graft flow was studied with transit time flowmetry, and angiography was performed before discharge in 29 cases. Midterm (at least 1 year after the operation) saphenous vein graft patency was assessed by coronary angiography or 3-dimensional coronary computed tomography in 27 cases. RESULTS: Postoperative angiography demonstrated a 100% patency rate and no significant stenosis at the connector-anastomosed sites. The 1-year patency rate of the saphenous vein grafts with the aortic connector system was 92.6%, with 2 cases of saphenous vein graft occlusion. Both of these cases had low graft flow and poor left ventricular function documented during the operation. CONCLUSION: Once surgical errors had been ruled out, the 1-year patency rate of proximal saphenous vein grafts anastomosed with the aortic connector system was favorable. Poor left ventricular function and low graft flow during the operation were risk factors for midterm graft occlusion. Selection of the target vessel and its runoff may also be an important determinant of long-term patency.