Second internal thoracic artery versus radial artery in coronary artery bypass grafting: a long-term, propensity score-matched follow-up study.

BACKGROUND: The best second arterial conduit for multiple arterial revascularization (MAR) is still a matter of debate. Previous studies on the benefit of either using the radial artery (RA) or the right internal thoracic artery (RITA) in coronary artery bypass grafting are not conclusive. The aim of our study was to compare the perioperative and long-term outcome of either RA or RITA grafts as second conduits for MAR. METHODS AND RESULTS: A consecutive series of 1001 patients undergoing first nonemergent coronary artery bypass grafting receiving either RA or RITA as second graft for MAR between 2001 and 2010 were studied. There were 277 patients receiving a RITA and 724 patients receiving a RA in addition to a left internal thoracic artery (LITA). Concomitant saphenous vein grafts (SVG) were grafted in addition as necessary. Propensity score-matched analysis was performed to compare the 2 groups, bilateral ITA±SVG (BITA±SVG group) and the LITA+RA±SVG group relative to overall survival and major adverse cardiac and cerebrovascular events-free survival. Hazard ratios and their 95% confidence intervals were estimated by COX regression stratified on matched pairs. The incidence of perioperative major adverse cardiac and cerebrovascular events was significantly lower in the BITA±SVG group (1.4% versus 7.6%, P<0.001). Overall survival (hazard ratio 0.23; 95% confidence interval 0.066-0.81; P=0.022) and major adverse cardiac and cerebrovascular events-free survival (hazard ratio 0.18; 95% confidence interval 0.08-0.42; P<0.001) were significantly better in the BITA±SVG group compared to the LITA+RA±SVG group. CONCLUSIONS: The results of our study provide strong evidence for the superiority of a RITA graft compared to RA as a second conduit in MAR.

Alternative valve-in-root concepts for redo procedures.

Since aortic root reoperations are challenging procedures, alternative lower-risk procedures should be considered in certain cases. Herein are presented two different approaches to high-risk root reoperations. The first patient, a 59-year-old male who had undergone root replacement 11 years previously with an Edwards Prima stentless valve, presented with severe aortic regurgitation and a heavily calcified aortic root. An open implantation of an Edwards Sapien valve was performed via an aortotomy distal to the calcified aortic root. The second patient, a 60-year-old female, underwent transapical implantation of an Edwards Sapien transcatheter valve for stenosis of the aortic valve in an aortic homograft implanted 11 years previously. The long-term durability of these implants has yet to be evaluated.

Pericardial tamponade due to perforation of a posterolateral branch of the circumflex artery caused by a perforating edge of a resected rib following orthopedic surgery in a 14-year-old patient.

A 14-year-old female patient with Marfan syndrome was resuscitated because of pericardial tamponade following orthopedic surgery to correct scoliosis. The emergency sternotomy revealed injury to a posterolateral branch of the circumflex artery caused by pericardial perforation by the stump of a previously resected rib. Cardiopulmonary bypass immediately restored the circulation, and the primarily dilated, noncontractile heart regained its contractile function. The small posterolateral branch was sewn over, and the sharp edge of the rib stump was smoothed by abrasion and covered with a Gore-Tex membrane. The patient recovered completely during the remainder of her postoperative stay.

Feasibility of coronary CT angiography for guidance of CABG.

OBJECTIVE: To assess the clinical safety and effectiveness of coronary revascularization in patients who underwent coronary artery bypass grafting (CABG) based exclusively on coronary computed tomography angiography (CCTA) results. METHODS: 53 patients (62.3 ± 7.1 years) underwent CCTA before a CABG surgery without prior invasive coronary angiography (ICA). Primary endpoints were all-cause mortality and major adverse cardiovascular events (MACE). The secondary endpoint was quality of life (QoL) assessed with the Minnesota Living with Heart Failure Questionnaire (MLHFQ). All were collected one year after the surgery. RESULTS: CCTA revealed multivessel coronary artery disease (CAD) in 52 patients. Indication for bypass surgery was made exclusively based on CCTA results. 136 distal anastomoses were performed. Assessment at 1 year (13.3 ± 1.4 months) was completed in 98.1% of the patients. MACE and mortality rates were 0%. The MLHFQ total score was 21.8 ± 8.7, and active lifestyle was maintained in all patients. CONCLUSIONS: In this proof of concept prospective pilot study, we observed that non-invasive coronary angiography may provide adequate anatomic detail to guide CABG surgery. Further study of this concept is warranted.

Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy.

BACKGROUND AND AIM OF THE STUDY: Although minimally invasive aortic valve replacement (MIAVR) through an anterolateral mini-thoracotomy has been shown to reduce surgical trauma, the technique is utilized only at a few selected heart surgery centers. The study aim was to demonstrate the implementation of a MIAVR program at the Innsbruck Medical University, Austria. METHODS: Between October 2006 and January 2009, a total of 315 patients underwent elective isolated aortic valve replacement (AVR). Of these patients, 87 (27.6%) received MIAVR, while the remainder (n = 228) underwent 'conventional' AVR by full sternotomy. In the MIAVR group, 76 patients (87%) were cannulated via the femoral artery. The mean EuroSCORE was 5.7 +/- 2.2 in the MIAVR group, and 6.7 +/- 2.9 in the AVR group (p < 0.001). Propensity score matching was used to reduce the impact of treatment selection in the comparison of MIAVR with conventional AVR. The propensity score was used to yield two matched groups by means of a 1:1 sample matching. RESULTS: The total operative, cardiopulmonary bypass and aortic cross-clamp times were significantly longer in the MIAVR group compared to the matched AVR group. The actuarial one-year survival was 96% in the MIAVR group, and 98% in the propensity-matched AVR group (p = 0.57). Reoperation due to bleeding was necessary in 4.6% of the MIAVR group (four patients, three by mini-thoracotomy) compared to 5.7% in the matched AVR group (n = 5; p = 0.38). A total of six MIAVR patients (6.9%) had complications from the cannulated groin, predominantly lymphatic fistula formation. Additionally, there was a trend towards a higher rate of renal insufficiency in the MIAVR group (p = 0.07). CONCLUSION: MIAVR can be safely implemented as routine cardiac surgery procedure, although the operative times are significantly longer. The early postoperative outcome was equal to that of the sternotomy approach, but postoperative complications were predominantly associated with femoral cannulation.

Intracavitary right coronary artery - Or just a wrap? A cardiac CT imaging series.

Intracavitary right coronary artery (RCA) is a very rare anomaly occurring in less than 0.1%1 and up to 0.4% reported by coronary computed tomography angiography (CTA).2 Literature is scarce, however its recognition is crucial, especially prior to surgical or interventional procedures such as coronary artery bypass graft (CABG) surgery, right heart catheterization or device implantation: Hereby the RCA is at risk of injury with fatal bleeding, or suturing a CABG anastomosis may be difficult or impossible.

Neurological outcome of septic cardioembolic stroke after infective endocarditis.

BACKGROUND AND PURPOSE: The aim of this study was to evaluate mortality and neurological outcomes of cardioembolic cerebral stroke in infective endocarditis (IE) patients requiring cardiac surgery. METHODS: A consecutive series of 214 patients undergoing cardiac surgery for IE was followed up for 20 years. In 65 patients (mean age, 52 years), IE was complicated by computed tomography- or magnetic resonance imaging-verified stroke (n=61) or transient ischemic attack (n=4). Perioperative (30-day) and long-term mortality was assessed with regression models adjusting for age. Complete neurological recovery of IE survivors was defined by a modified Rankin score of < or = 1 and a Barthel index of 20 points. RESULTS: Fifty of 61 stroke patients (81.9%) survived surgery. In comparison with nonstroke patients, the age-adjusted perioperative mortality risk was 1.70-fold (95% CI, 0.73 to 3.96, P=0.22) higher and long-term mortality risk was 1.23-fold (95% CI, 0.72 to 2.11, P=0.45) higher in stroke patients. Patients with complicated stroke (meningitis, hemorrhage, or brain abscess) showed a higher perioperative mortality rate (38.9% vs 8.5%, P=0.007) but no higher neurological complication rate than patients with uncomplicated ischemic stroke. Complete neurological recovery was achieved in 35 IE survivors (70%, 95% CI, 55% to 82%). However, in the case of middle cerebral artery stroke, recovery was only 50% and was significantly lower compared with non-middle cerebral artery stroke (P=0.012). CONCLUSIONS: Uncomplicated IE-related stroke showed a favorable prognosis with regard to both long-term survival and neurological recovery. The formidable risk of secondary cerebral hemorrhage due to cardiac surgery seems to be much lower than previously thought.

Mitral valve repair provides improved outcome over replacement in active infective endocarditis.

OBJECTIVES: Mitral repair in active infective endocarditis still remains controversial. Several studies demonstrate the feasibility of mitral repair in infective endocarditis; however, superiority of repair has never been shown. The aim of the investigation was to compare valve repair and valve replacement in respect to the extent of destruction and to analyze survival, recurrent endocarditis, and reoperation (event-free survival). METHODS: Sixty-eight consecutive patients underwent surgical intervention for mitral endocarditis. Thirty-four (50%) patients had valve repair, and 34 (50%) patients had valve replacement. Leaflet destruction involving at least one mitral leaflet was present in 15 (44.1%) patients of the repair group and 11 (32.4%) patients of the replacement group. Repair of the mitral annulus with pericardium was performed in 4 (11.8%) patients in the repair group and 3 (8.8%) patients in the replacement group. Patients in both groups were similar concerning the progression of valvular destructions and comorbidities. RESULTS: Hospital mortality was 11.8% (8 patients). No significant differences were found in all baseline parameters, with the exception of a higher incidence of previous septic embolism and sepsis in the repair group. Actuarial event-free survival at 1 year was 88.2% in the repair group compared with 67.7% in the replacement group, and 5-year event-free survival was 80.4% in the repair group and 54.6% in the replacement group (P = .015). Mitral valve repair remained the superior treatment regarding event-free survival in the multivariate analysis (hazard ratio, 0.33; 95% confidence interval, 0.12-0.93; P = .02). CONCLUSIONS: Mitral valve repair offers excellent early and late results and is the preferable treatment option in the surgical therapy of native infective endocarditis.

Unusual late clinical manifestation of Bland-White-Garland syndrome as sudden cardiac death survival.

In this report, we present an extremely late clinical manifestation of Bland-White-Garland syndrome in a 53-year old woman who was ttransferred to our hospital after successful cardiopulmonary resuscitation. Coronary angiography revealed a dilated right coronary artery giving rise to multiple dominant septal collaterals to the left coronary artery (LCA) which arose from the pulmonary trunk (left to right shunt 0.15). Cardiac computed tomography identified a retropulmonary course of the LCA. The patient underwent cardiac surgery with LCA occlusion and triple coronary bypass grafting.

Treatment of destructive aortic valve endocarditis with the Freestyle Aortic Root Bioprosthesis.

BACKGROUND: Successful treatment of destructive aortic valve endocarditis with annular abscess formation requires extensive surgical debridement and reconstruction of the left ventricular outflow tract and aortic root. Homograft aortic roots are the conduits of choice, but because they are not available in all cases, alternative conduits are needed. METHODS: Owing to its features, which are comparable to those of homografts, the Freestyle aortic root xenograft was used in 10 consecutive patients aged between 32 and 77 years. All patients had extensive abscess formation, 5 presented with prosthetic valve endocarditis, 2 had additional mitral valve endocarditis requiring partial leaflet resection and reconstruction, 1 patient had an additional fistula into the right atrium, and 1 required coronary bypass. One patient developed a septic ventricular septal defect and fistula into the right atrium with tricuspid valve endocarditis. RESULTS: None of the patients required reoperation for bleeding. Two (20%) patients died in the postoperative period, 1 due to multiorgan failure, and 1 due to preexisting invasive pulmonary aspergillosis. At autopsy, neither had evidence of intrapericardial hematoma or suture dehiscence. One patient died 13 months postoperatively without clinical signs of valve dysfunction or recurrent endocarditis. All other patients are well at 12 to 42 months after surgery. Clinical examination and echocardiography at the most recent follow-up showed no signs of valve dysfunction, recurrent fistulation, or endocarditis. CONCLUSIONS: The Freestyle aortic root appears to be an acceptable alternative to homografts in the treatment of severe endocarditis. Long-term valve durability in younger patients, however, remains to be determined.

Simple adaptations of surgical technique to critically reduce the risk of postoperative sternal complications in patients receiving bilateral internal thoracic arteries.

OBJECTIVES: Limited blood supply to the thoracic chest wall is a known risk factor for sternal wound complications after CABG. Therefore, bilateral internal thoracic arteries are still rarely utilized despite their proven superior graft patency. The aim of our study was to analyse whether modification of the surgical technique is able to limit the risk of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. METHODS: All 418 non-emergent CABG patients receiving bilateral internal thoracic artery CABG procedures (BITA) from January 2001 to January 2012 were analysed for sternal wound complications. Surgical technique together with known risk factors and relevant comorbidity were analysed for their effect on the occurrence of sternal wound complications by means of multivariate logistic regression analysis. RESULTS: Sternal wound complications occurred in 25 patients (5.9%), with a sternal dehiscence rate of 2.4% (10 patients). In multivariate analysis, diabetes (odds ratio [OR]: 4.8, 95% CI: 1.9-11.7, P=0.001), but not obesity (OR: 1.6, 95% CI: 0.7-4.2, P=0.28) or chronic obstructive pulmonary disease (OR: 2.2, 95% CI: 0.87-5.6, P=0.1) was a relevant comorbid condition for sternal complications. Skeletonization of ITA grafts (OR: 0.17, 95% CI: 0.06-0.5, P=0.001) and the augmented use of sternal wires (OR: 0.24, 95% CI: 0.06-0.95, P=0.04) were highly effective in preventing sternal complications. The use of platelet-enriched-fibrin glue (PRF) sealant, however, was associated with more superficial sternal infections (OR: 3.7, 95% CI: 1.3-10.5, P=0.02). CONCLUSIONS: Adjusted for common risk factors, skeletonization of BITA grafts together with augmented sternal wires is effective in preventing sternal complications. The use of PRF sealant, however, increased the risk for superficial wound complications.

Assessment of ventricular contractile function during orthotopic liver transplantation.

Hemodynamic alterations are a well-known phenomenon that influence the outcome of orthotopic liver transplantation (OLT). Whether or not myocardial dysfunction, which has various causes, contributes to this instability is still debated. Previous transesophageal echocardiography (TEE) studies have presented controversial data, not leading to final clarification. This is mainly because the impact of other contributing factors (inotropic support, alternating preload conditions and temperature) remained unaccounted for. We therefore measured the left ventricular shortening fraction (LVSF), a parameter reflecting myocardial contractility, in 10 consecutive patients undergoing OLT without veno-venous bypass. We measured during preparation (PP), during the anhepatic (AP) phase and the immediate reperfusion phase (RP). During the AP we observed a significant decrease of LVSF which never fell to subnormal levels in the majority of our patients, whereas during the RP, LVSF returned to PP values. These findings support the assumption that myocardial function is influenced by OLT, but that it plays only a minor role in the occurrence of hemodynamic instability, which could mainly be attributed to volume fluctuations.