Left heart bypass for repair of aortic coarctation in children: Technical tips and pitfalls.

Spinal cord injury secondary to coarctation repair in children is a serious, though relatively uncommon, complication. Several measures have been proposed to minimize this risk, which seems to affect more older children than neonates and those with inadequate collateral circulation. Left heart bypass has been proposed as a protective strategy.

Hybrid Left Heart Bypass Circuit for Repair of the Descending Aorta in an 8-kg Williams Syndrome Patient.

A 1-year old male patient with Williams syndrome and multiple prior interventions presented for surgical repair of his descending aorta (DA) through a left thoracotomy. Concerns for significant bleeding and spinal cord protection led the care team to consider a left heart bypass (LHB) circuit with options for pump sucker use, heat exchange capacity, and the possibility of converting to traditional cardiopulmonary bypass (CPB). A traditional CPB circuit with a roller-head arterial pump was assembled with a bypass line around the cardiotomy venous reservoir (CVR). Excluding the CVR with this line allowed for a closed LHB circuit. A second pump head was integrated to both recirculate the CVR volume and to serve as a means for controlled volume administration to the closed LHB circuit. Pump sucker return directed to the CVR could easily be transfused back to the patient. The patient was placed on the hybrid LHB circuit and cooled to 32°C. DA clamps were placed. Upper body dynamic blood pressure was managed for a target mean of 50 mmHg, the left atrial pressure (LAP) was maintained in the 5-7 mmHg range, and the nonpulsatile lower body blood pressure was targeted at 40-50 mmHg. Cerebral near-infrared spectroscopy (NIRS) helped guide volume and pressure management. The surgeons placed two long-segment patches on the DA, moving clamps as needed. The patient was rewarmed and separated from the hybrid LHB circuit after 82 minutes. Closed circuit LHB can be provided with a roller-head hybrid circuit incorporating an oxygenator for gas exchange, central cooling and warming, and arterial line filtration along with a CVR for pump sucker use and controlled transfusion to the patient.

Treatment of thoracoabdominal aortic aneurysm by prosthetic vessel replacement under left heart bypass. / å·¦å¿ƒè½¬æµä¸‹äººå·¥è¡€ç®¡ç½®æ¢æœ¯æ²»ç–—èƒ¸è ¹ä¸»åŠ¨è„‰ç˜¤.

OBJECTIVES: Thoracoabdominal aortic aneurysm (TAAA) prosthetic vessel replacement is one of the most complex operations in the field of cardiovascular surgery. The key to success of this operation is to prevent and avoid ischemia of important organs while repairing TAAA. This study aims to summarize and analyze the effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA. METHODS: Data of 15 patients with TAAA who underwent prosthetic vessel replacement under left heart bypass in Xiangya Hospital of Central South University were retrospectively analyzed. According to Crawford classification, there were 2 cases of type I, 8 cases of type II, 3 cases of type III, and 2 cases of type V. There were 14 cases of selective operation and 1 case of emergency operation. All operations were performed under left heart bypass, and cerebrospinal fluid drainage was performed before operation. Left heart bypass was established by intubation of left inferior pulmonary vein and distal abdominal aorta or left femoral artery. The thoracoabdominal aorta was replaced segment by segment. After aortic dissection, the kidneys were perfused with cold crystalloid renal protective solution, and the celiac trunk and superior mesenteric artery were perfused with warm blood. RESULTS: One patient with TAAA after aortic dissection of type A died. During the operation, straight blood vessels were used to repair TAAA, and the celiac artery branches were trimmed into island shape and anastomosed with prosthetic vessels. After the operation, massive bleeding occurred at the anastomotic stoma, then anaphylactic reaction occurred during massive blood transfusion, resulting in death. One patient suffered from paraplegia due to ischemic injury of spinal cord. The other patients recovered well and were discharged. The postoperative ventilation time was (16.5±13.8) h and the postoperative hospital stay was (10±4) d. The amount of red blood cell transfusion was (13±9) U. The patients were followed up for 2 months to 2 years, and the recovery was satisfactory. CONCLUSIONS: The effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA is good, which is worthy of clinical promotion.

Treatment of thoracoabdominal aortic aneurysm by prosthetic vessel replacement under left heart bypass / 中南大学学报(医学版)

OBJECTIVES@#Thoracoabdominal aortic aneurysm (TAAA) prosthetic vessel replacement is one of the most complex operations in the field of cardiovascular surgery. The key to success of this operation is to prevent and avoid ischemia of important organs while repairing TAAA. This study aims to summarize and analyze the effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA.@*METHODS@#Data of 15 patients with TAAA who underwent prosthetic vessel replacement under left heart bypass in Xiangya Hospital of Central South University were retrospectively analyzed. According to Crawford classification, there were 2 cases of type I, 8 cases of type II, 3 cases of type III, and 2 cases of type V. There were 14 cases of selective operation and 1 case of emergency operation. All operations were performed under left heart bypass, and cerebrospinal fluid drainage was performed before operation. Left heart bypass was established by intubation of left inferior pulmonary vein and distal abdominal aorta or left femoral artery. The thoracoabdominal aorta was replaced segment by segment. After aortic dissection, the kidneys were perfused with cold crystalloid renal protective solution, and the celiac trunk and superior mesenteric artery were perfused with warm blood.@*RESULTS@#One patient with TAAA after aortic dissection of type A died. During the operation, straight blood vessels were used to repair TAAA, and the celiac artery branches were trimmed into island shape and anastomosed with prosthetic vessels. After the operation, massive bleeding occurred at the anastomotic stoma, then anaphylactic reaction occurred during massive blood transfusion, resulting in death. One patient suffered from paraplegia due to ischemic injury of spinal cord. The other patients recovered well and were discharged. The postoperative ventilation time was (16.5±13.8) h and the postoperative hospital stay was (10±4) d. The amount of red blood cell transfusion was (13±9) U. The patients were followed up for 2 months to 2 years, and the recovery was satisfactory.@*CONCLUSIONS@#The effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA is good, which is worthy of clinical promotion.

Left heart bypass versus circulatory arrest for open repair of thoracoabdominal aortic pathologies.

BACKGROUND: Most large-volume centres use left heart bypass (LHB) as their preferred organ protection strategy during repair of descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) pathologies. We investigate the use of hypothermic circulatory arrest (HCA) for similar pathologies and compare the outcomes of both. METHODS: A PubMed, Embase and Scopus search for studies in English on LHB versus HCA for repair of DTA and TAA pathologies published from inception till February 2020 was performed. Our analysis excluded studies without direct comparison of the two organ protection strategies. Clinical endpoints that were studied were 30-day mortality, post-operative stroke, spinal cord deficit, renal failure and respiratory failure. Random effects meta-analyses of the effect of the two strategies across all clinical endpoints were conducted. RESULTS: HCA is non-inferior to LHB across all clinical endpoints. In terms of 30-day mortality (odds ratio (OR) 1.19, 95% confidence interval (CI) 0.31-4.59, P = 0.14, I2 = 49%), stroke (OR 0.41, 95% CI 0.12-1.39, P = 0.97, I2 = 0%), spinal cord deficit (OR 0.56, 95% CI 0.22-1.45, P = 0.78, I2 = 0%), renal failure (OR 1.33, 95% CI 0.37-4.76, P = 0.98, I2 = 0%) and respiratory failure (OR 0.86, 95% CI 0.37-1.97, P = 0.16, I2 = 46%), there was no statistically significant difference between the two cohorts. CONCLUSION: Evidence is limited, but suggests that HCA alone provides adequate organ protection during repair of DTA and TAA pathologies, and has equivalent outcomes when compared to LHB.

Impact of age at bidirectional cavopulmonary anastomosis on haemodynamics after Fontan operation.

BackgroundsThe aim of this study was to assess the impact of age at bidirectional cavopulmonary anastomosis on haemodynamics after total cavopulmonary connection. METHODS: We conducted a retrospective analysis of 100 consecutive patients who underwent total cavopulmonary connection from 2010 to 2014. All patients had previously undergone bidirectional cavopulmonary anastomosis. These patients were classified into two groups according to age at bidirectional cavopulmonary anastomosis: younger group, 6 months (n=67). RESULTS: The proportion of hypoplastic left heart syndrome was higher in the younger group (48 versus 4%). After total cavopulmonary connection, the chest tube period was longer in the younger group (10.1±6.6 versus 6.7±4.5 days; p=0.009). Catheterisation 6 months after total cavopulmonary connection revealed that pulmonary artery pressure was higher (11.5±1.9 versus 10.4±2.1 mmHg; p=0.017) and Nakata index was lower (219±79 versus 256±70 mm2/m2; p=0.024) in the younger group. In patients with a non-hypoplastic left heart syndrome, there was no difference in post-operative haemodynamics between two groups, but the total amount of chest drainage after total cavopulmonary connection was larger in the younger group (109±95 versus 55±40 ml/kg; p=0.044). CONCLUSIONS: Early bidirectional cavopulmonary anastomosis did not affect the outcome of total cavopulmonary connection. Longer chest tube period, smaller pulmonary artery, and higher pulmonary artery pressure after total cavopulmonary connection were recognised in early bidirectional cavopulmonary anastomosis patients, especially in hypoplastic left heart syndrome.

Left ventricular hypertrophy as protective factor after bypass grafting.

Left ventricular hypertrophy (LVH) is a well established cardiovascular risk factor, accounting for an increase in cardiovascular morbid-mortality, although how much the magnitude and the kind of LVH could affect cardiovascular outcomes is in large part unknown. We speculate that mild LVH in absence of left ventricular (LV) chamber dilation, could play a protective role towards functional capacity, clinical outcome, cardiovascular and total morbi-mortality in conditions in which LV systolic function is generally reduced. Accordingly to many epidemiological observations, the availability of extra-quote of systolic function could lead to a significative improvement in the final outcome of some kinds of heart patients, as those undergoing bypass-grafting, where the stress for heart and cardiovascular system is always high. We suppose that the functional reserve available for patients with LVH could make the difference with respect to other patients undergoing myocardial revascularization. Similarly, the availability of a contractile reserve warranted by LVH could ensure a little gain in the outcome for patients after other major cardiovascular events (such as myocardial infarction or other heart surgery as surgical valve replacement). However, our hypothesis only involves mild LVH without LV chamber dilation, that is the initial stage of "non-dilated concentric" LVH and "non-dilated eccentric" LVH according to the new four-tiered classification of LVH based on relative wall thickness and LV dilation. Support for our hypothesis derives from the well-known protective role of systolic function that is a major factor in almost all cardiovascular diseases, where LV ejection fraction (LVEF) has shown to significantly improve quality of life, as well as morbidity and mortality. The knowledge that mild LVH in absence of LV chamber dilation is not as harmful in such conditions as believed at present could make avoidable some drugs prescription in some stages of the disease. Furthermore, it may allow a better evaluation of the risk profile of patients with LVH undergoing some cardiovascular major events like bypass grafting, myocardial infarction or surgical heart valve replacement.

Outcomes of Left Heart Bypass Versus Circulatory Arrest in Elective Open Surgical Descending and Thoraco-abdominal Aortic Repair.

OBJECTIVES: To compare early (30 day mortality and major complications) and midterm (survival) outcomes in elective open surgical descending and thoraco-abdominal aortic repair using left heart bypass (LHB) versus hypothermic circulatory arrest (HCA) for organ protection, hypothesising non-inferiority of HCA management. METHOD: This was a retrospective clinical cohort study with cross sectional follow-up. All elective (n = 90) descending or thoraco-abdominal aortic repairs performed between 2004 and 2015 using either LHB (n = 57) or HCA (n = 33) were included. Pre- and intra-operative variables were evaluated by univariate statistical analysis. Thirty day and follow-up mortality were primary endpoints; major complications were secondary endpoints. Propensity score matching was employed to adjust for selection bias. Kaplan-Meier methods were used to estimate midterm survival. RESULTS: Overall 30 day mortality was 8/90 (8.9%): 6/57 (10.5%) using LHB vs. 2/33 (6.1%) using HCA, p = .47. Five patients (5.6%) suffered paraplegia: 3/57 (5.3%) using LHB vs. 2/33 (6.1%) using HCA, p = .87. Stroke occurred in 6/57 (11%) vs. 2/33 (6.1%), p = .76; renal failure in 27/57 (47%) vs. 19/33 (58%), p = .90; and respiratory failure in 17/57 (30%) vs. 11/33 (33%), p = .68. In 26 propensity score matched pairs, findings remained unaltered. Total follow-up was 443 patient years (median 4.9 years). Estimated survival was 78% at 1 year and 77% at 5 years in LHB vs. 72% and 67%, respectively, with HCA; there were no significant inter-group differences, before or after propensity score matching. CONCLUSIONS: In elective descending or thoraco-abdominal aortic repair, no statistically significant differences in 30 day mortality, major complications, or follow-up survival were found when LHB and HCA were compared. These findings remained after propensity score matching.

Impact of Left Heart Bypass on Arterial Oxygenation During One-Lung Ventilation for Thoracic Aortic Surgery.

OBJECTIVE: The aim of this study was to reveal the mechanism of improved arterial oxygenation by measuring the changes in oxygenation before and after initiation of left heart bypass (LHB) during one-lung ventilation (OLV) for thoracic aortic surgery. DESIGN: Prospective, observational study. SETTING: Single-institution, private hospital. PARTICIPANTS: The study comprised 50 patients who underwent aortic surgery via a left thoracotomy approach with LHB circulatory support. INTERVENTIONS: Patients were ventilated using pure oxygen during OLV, and the ventilator setting was left unchanged during the measurement period. MEASUREMENTS AND MAIN RESULTS: The measurement of partial pressure of arterial oxygen (PaO2) was made at the following 4 time points: 2 minutes after heparin infusion (point 1 [P1]), 2 minutes after inflow cannula insertion through the left pulmonary vein (P2), immediately before LHB initiation (P3), and 10 minutes after LHB initiation (P4). The mean±standard deviation (mmHg) of PaO2 measurements at the P1, P2, P3, and P4 time points were 244±121, 250±123, 419±122, and 430±109, respectively, with significant increases between P1 and P3, P1 and P4, P2 and P3, and P2 and P4 (p<0.0001, respectively). No significant increase in PaO2 was seen between P1 and P2 or between P3 and P4. CONCLUSIONS: The improved arterial oxygenation during OLV in patients who underwent thoracic aortic surgery using LHB can be attributed to the insertion of an inflow cannula via the left pulmonary vein into the left atrium before LHB.

Left heart bypass for thoracoabdominal aortic aneurysm repair: technical aspects.

There are different surgical techniques for providing circulatory support during the repair of thoracoabdominal aortic aneurysms. They all aim at reducing the afterload of the heart and the preservation of distal organ perfusion. Partial or total extracorporeal circulation with or without cooling and left heart bypass (LHB) are actually the most used surgical approaches. The objective of this study was to describe and comment on the technical aspects of the LHB. We briefly describe our results and put them into perspective based on the current literature.

Indicadores pronósticos clínicos en el posoperatorio de cirugía cardiovascular pediátrica y su relación con la cinética del estrés oxidativo / Prognostic indicators after cardiac surgery in children and their relationship with the oxidative stress response

Objetivos. Analizar la evolución de parámetros de estrés oxidativo en el posoperatorio de cirugía cardiovascular pediátrica y correlacionarlos con diferentes indicadores clínicos pronósticos. Material y métodos. Treinta niños, de entre un mes y 14 años, peso > 5 kg, sometidos a circulación extracorpórea. Se obtuvieron muestras preoperatoria, posoperatoria inmediata y tras 18-20 h. Se analizó la capacidad de peroxidación lipídica de las membranas celulares mediante la cuantificación de productos de reacción con el ácido tiobarbitúrico, cuyo principal representante es el malondialdehído; se cuantificó el contenido celular de glutatión total, oxidado y reducido (representantes de la respuesta antioxidante). Se analizaron las variables clínicas que permitieran establecer una puntuación para el síndrome de respuesta inflamatoria sistémica asociado a circulación extracorpórea. Resultados. Treinta pacientes con una mediana de edad de 4,1 años (rango intercuartílico [RIC]: 2,7; 8,0); el 62,1% eran niñas; mediana de desviaciones estándar de peso −0,39 (RIC: −0,76; 0,24), de talla −0,22 (RIC: −0,74; 0,27) y de IMC −0,43 (RIC: −1; 0,45). Mediana de tiempo quirúrgico 79 min (RIC: 52,5; 125,5), mediana de pinzamiento 38,5 min (RIC: 22; 59). Aumentó el malondialdehído y disminuyó el glutatión en ambos momentos posoperatorios, con clara correlación directa, estadísticamente significativa, del tiempo de circulación extracorpórea con el porcentaje de descenso de glutatión total entre preoperatorio y posoperatorio inmediato y entre el preoperatorio y el posoperatorio tardío. Hubo una correlación estadística entre los niveles de glutatión total tras 18-20 h posoperatorias y el tiempo de duración de la ventilación mecánica y la pertenencia al grupo de síndrome de respuesta inflamatoria sistémica. Conclusiones. La circulación extracorpórea activa mediadores inflamatorios, máximo tras el pinzamiento aórtico, mejorando tras 24 h, siendo dependiente de los tiempos quirúrgicos. El desarrollo de respuesta inflamatoria está asociado a una mayor duración de la ventilación mecánica, una estancia más prolongada en Cuidados Intensivos, puntuaciones mayores del Modelo de Aristóteles y tiempos más largos quirúrgicos. Los que no cumplen criterios de respuesta inflamatoria tienen más niveles de glutatión en el posoperatorio tardío (AU)

Objectives. To analyse the trend in lipid peroxidation and antioxidant response as key markers of oxidative stress after paediatric cardiovascular surgery, and compare them with other internationally accepted clinical prognostic indicators. Patients and methods. A prospective study was conducted on 30 children aged one month to 14 years, weight > 5 kg, undergoing cardiopulmonary bypass surgery. Blood samples were taken just before the intervention, immediately after surgery, and after 18-20 h. Cell membrane lipid peroxidation was analysed by quantifying malondialdehyde, as well as measuring total glutathione (oxidized and reduced), as representatives of antioxidant response. An analysis was also performed on clinical variables for establishing a score for the systemic inflammatory response syndrome associated with cardiopulmonary bypass. Results. The study included 30 children with a mean age of 4.1 years old (interquartile range [IQR]: 2.7; 8.0). Of these, 62.1% were girls. The standard deviation of the median weight was −0.39 (IQR: −0.76; 0.24), the median height was −0.22 (IQR: −0.74; 0.27), and the median BMI was −0.43 (IQR: −1; 0.45). The final surgery times were divided into 2 parts: total time of extracorporeal circulation, with a mean of 79 min (IQR: 52.5; 125.5), and the clamping time, a measurement included in the previous figure with a mean value of 38.5 min (IQR: 22; 59). Malondialdehyde increased and glutathione decreased in postoperative time, with clear, statistically significant direct correlation between time of extracorporeal circulation and percentage decrease in total glutathione between preoperative and immediate postoperative time, and a decline between the preoperative and late postoperative. There was a statistical correlation between total glutathione levels at 18-20 h postoperatively and the duration of mechanical ventilation and inflammatory systemic response syndrome. Conclusions. Surgery with extracorporeal circulation performed in children activates inflammatory mediators, being maximum after aortic clamping, and improving after the first 24 h. The level of oxidative stress activation depends on surgical times. The development of systemic inflammatory response syndrome is associated with longer duration of mechanical ventilation, longer stay in intensive care, higher scores in the Aristotle model and longer surgical times. Those who do not meet criteria for inflammatory response have higher levels of glutathione in first 24 h (AU)

Takayasu's or tuberculous arteritis?

Takayasu's arteritis (TA) is a large vessel vasculitis of unknown aetiology characterised by involvement of the aorta and its major branches. Tuberculous arteritis of the aorta is an uncommon condition usually secondary to the dissemination of Mycobacterium tuberculosis infection from the mediastinum and/or lung to the adjacent aorta; this may mimic TA. We report a case of a 23-year-old woman with cutaneous granulomatous vasculitis and saccular aneurysmal dilation of the aorta and large vessels, and highlight the findings shared by TA and tuberculous arteritis.

An insight into short- and long-term mechanical circulatory support systems.

Cardiogenic shock due to acute myocardial infarction, postcardiotomy syndrome following cardiac surgery, or manifestation of heart failure remains a clinical challenge with high mortality rates, despite ongoing advances in surgical techniques, widespread use of primary percutaneous interventions, and medical treatment. Clinicians have, therefore, turned to mechanical means of circulatory support. At present, a broad range of devices are available, which may be extracorporeal, implantable, or percutaneous; temporary or long term. Although counter pulsation provided by intra-aortic balloon pump (IABP) and comprehensive mechanical support for both the systemic and the pulmonary circulation through extracorporeal membrane oxygenation (ECMO) remain a major tool of acute care in patients with cardiogenic shock, both before and after surgical or percutaneous intervention, the development of devices such as the Impella or the Tandemheart allows less invasive forms of temporary support. On the other hand, concerning mid-, or long-term support, left ventricular assist devices have evolved from a last resort life-saving therapy to a well-established viable alternative for thousands of heart failure patients caused by the shortage of donor organs available for transplantation. The optimal selection of the assist device is based on the initial consideration according to hemodynamic situation, comorbidities, intended time of use and therapeutic options. The present article offers an update on currently available mechanical circulatory support systems (MCSS) for short and long-term use as well as an insight into future perspectives.

Implante de un stent en la anastomosis del colector a la aurícula izquierda tras cirugía correctora de drenaje venoso pulmonar anómalo total / Stent Implantation in the Anastomosis After Correction of a Total Anomalous Pulmonary Venous Connection

No disponible

Evaluation of platelet aggregability during left ventricular bypass using a MedTech MagLev VAD in a series of chronic calf experiments.

The impact of continuous flow left ventricular assist device (LVAD) pumping on platelet aggregation was investigated in animal experiments utilizing six calves. A single-use MagLev centrifugal blood pump, MedTech MagLev, was used to bypass the calves' hearts from the left atrium to the descending aorta at a flow rate of 50 ml/kg/min. The LVAD's impact on blood coagulation activities was evaluated based on the platelet aggregability, which was measured with a turbidimetric assay method during the preoperative, operative, and postoperative periods. Heparin and warfarin were used for anticoagulation, while aspirin was used for the antiplatelet therapy. A decrease in platelet aggregation immediately after the pump started was observed in the cases of successful long-term pump operation, while the absence of such a decrease might have caused coagulation-related complications to terminate the experiments. Thus, the platelet aggregability was found to be significantly affected by the pump, and its initial trend may be related to the long-term outcome of the mechanical circulatory support.

Cirugía de bypass en la enfermedad coronaria multivasos: tratamiento antiguo con vigencia actual / Bypass surgery in multivessel coronary disease: old and contemporary relevance treatment

Objetivo: Evaluar nuestros resultados a corto y largo plazo en la cirugía de bypass para el grupo de enfermedad coronaria multivasos (3 vasos y/o tronco izquierdo). Analizar recientes estudios que comparan stent liberador de drogas (DES del inglés Drug eluting stents) versus cirugía. Actualizar recomendaciones. Métodos: Se analiza retrospectivamente 121 pacientes consecutivos tratados con cirugía de revascularización miocárdica por enfermedad coronaria multivasos entre diciembre de 1998 y febrero de 2008 y se comparan con los resultados de la literatura. Además se evaluó la presencia de factores de riesgo preoperatorios que influenciarían los resultados. Resultados: La mortalidad hospitalaria (30 días) fue de 2.5%. A un seguimiento de 4.4 años, en 100 pacientes se observa una sobrevida de 93.21% y una necesidad de repetir revascularización de 3.3%. Conclusión: Se observa un aumento de los factores de riesgo (edad y procedimientos coronarios previos, sean quirúrgicos o intervencionistas) en la población que acude a cirugía, a pesar de lo cual la morbi-mortalidad continúa baja, incluso en el seguimiento a largo plazo. Nuestros resultados concuerdan con los de las publicaciones internacionales de centros avanzados. Estudios randomizados y observacionales de estos centros muestran, en la enfermedad coronaria multivasos, que la cirugía tiene menos eventos adversos cardiacos y cerebro vasculares que el stent y ventaja en la sobrevida a largo plazo. La cirugía se mantiene como la opción preferida para la enfermedad coronaria multivasos no aguda, en especial cuando las lesiones coronarias son anatómicamente complejas.

Objective: With this study we have assessed our early and late surgical outcomes in patients with Multivessel Coronary Artery Disease (CAD) (defined as 3 coronary vessels or Left Main Coronary Disease) treated with Coronary Artery Bypass Grafting (CABG) Surgery. We have analyzed studies comparing Drug Eluting Stent (DES) versus CABG Surgery to treat Multivessel CAD. We have reviewed all up to date guidelines and recommendations. Methods: We have retrospectively analyzed 121 consecutive patients with multivessel CAD treated with CABG surgery. Results: In-hospital mortality (30 days) was 2,5 %. A subsequent follow up of 100 patients after 4,4 years showed a rate of survival of 93.21 % and the need for repeat myocardial revascularization procedures in 3,3%. Conclusion: CABG surgery to treat Multivessel CAD has low morbidity and mortality even with increase in the risk factors of the population.We have similar results to other published Randomized Controlled and Observational Trials. These studies show that CABG surgery has lower rates of Mayor Adverse Cardiac and Cerebrovascular Events (MACCE) and higher survival rates than DES. Surgery is still the treatment of choice for non-acute multivessel CAD, especially when there is a complex anatomy.

Surgical repair of coarctation of aorta in adults under left heart bypass.

OBJECTIVE: To describe our experience with repair of coarctation of the aorta in adults using left heart bypass. METHODS: From November 2007 to October 2009, eight adult patients with coarctation of the aorta underwent surgical repair under circulatory support using a left atrium to femoral artery bypass circuit, with graft interposition tube through left posterolateral thoracotomy. Five patients were female, with mean age of 31.5 ± 13.1 years. All patients had hypertension and others associated cardiovascular diseases. RESULTS: There were no deaths or neurological complications. The mean surgical time was 308 minutes with mean left heart bypass and distal aortic clamping time of 73 and 65 minutes respectively. Postoperative bleeding was 696 ml in average. Six patients developed severe hypertension postoperatively requiring intravenous vasodilators. The mean length of stay was 9 days. A significant reduction of gradient blood pressure occurred. Echocardiographic follow-up up to two months postoperatively showed mean aortic / graft gradient of 20.3 mmHg. CONCLUSION: In this series the use of left heart bypass showed to be a safe option in the surgical correction of coarctation of the aorta in adults, especially in patients with abnormal aortic wall. There was no spinal cord ischemia in the cases studied.

Correção cirúrgica da coarctação da aorta em adultos sob assistência circulatória extracorpórea esquerda / Surgical repair of coarctation of aorta in adults under left heart bypass

OBJETIVO: Descrever a experiência do serviço com a correção da coarctação da aorta em adultos utilizando assistência circulatória esquerda. MÉTODOS: De novembro de 2007 a outubro de 2009, oito pacientes adultos com coarctação da aorta foram submetidos a correção cirúrgica com interposição de enxerto tubular através de toracotomia póstero-lateral esquerda e uso de assistência circulatória com uso de circuito átrio esquerdo e artéria femoral. Cinco pacientes eram do sexo feminino e tinham idade média de 31,5 ± 13,1 anos. Todos tinham hipertensão arterial sistêmica (HAS) e apresentavam doenças cardiovasculares associadas. RESULTADOS: Não houve óbitos ou complicações neurológicas. O tempo médio cirúrgico foi de 308 minutos, o tempo médio de assistência circulatória de 73 minutos e o de pinçamento aórtico médio de 65 minutos. O sangramento médio no pós-operatório foi de 696 ml. Seis pacientes evoluíram com HAS grave no pós-operatório, sendo necessário uso de vasodilatadores endovenosos. As altas hospitalares ocorreram em média no 9º dia pós-operatório. Houve redução significativa do gradiente médio da pressão arterial sistêmica. O seguimento ambulatorial com ecocardiograma até dois meses de pós-operatório demonstrou gradiente aorta/enxerto médio de 20,3 mmHg. CONCLUSÃO: O uso da assistência circulatória esquerda pode ser uma opção na correção cirúrgica da coarctação da aorta em adultos, principalmente em pacientes com alterações parede da aorta, não sendo observada isquemia medular nos casos estudados.

OBJECTIVE: To describe our experience with repair of coarctation of the aorta in adults using left heart bypass. METHODS: From November 2007 to October 2009, eight adult patients with coarctation of the aorta underwent surgical repair under circulatory support using a left atrium to femoral artery bypass circuit, with graft interposition tube through left posterolateral thoracotomy. Five patients were female, with mean age of 31.5 ± 13.1 years. All patients had hypertension and others associated cardiovascular diseases. RESULTS: There were no deaths or neurological complications. The mean surgical time was 308 minutes with mean left heart bypass and distal aortic clamping time of 73 and 65 minutes respectively. Postoperative bleeding was 696 ml in average. Six patients developed severe hypertension postoperatively requiring intravenous vasodilators. The mean length of stay was 9 days. A significant reduction of gradient blood pressure occurred. Echocardiographic follow-up up to two months postoperatively showed mean aortic / graft gradient of 20.3 mmHg. CONCLUSION: In this series the use of left heart bypass showed to be a safe option in the surgical correction of coarctation of the aorta in adults, especially in patients with abnormal aortic wall. There was no spinal cord ischemia in the cases studied.