HTK solution helps to preserve endothelial integrity of saphenous vein: an immunohistochemical and ultrastructural analysis.

The aim of the study is to demonstrate the ability of HTK (Histidine-tryptophan-ketoglutarate) solution to preserve endothelium. Ten saphenous veins (SVs) were prospectively collected from 10 patients who underwent coronary artery bypass grafting (CABG). The SVs were divided into two sets of segments, one of which preserved in HTK solution at 4°C (group A), and the other preserved at 4°C in saline solution NaCl 0.9% (group B); ten pieces from the SVs were processed as control. The control sample was fixed in 10% neutral buffered formalin immediately after harvesting. The observation lasted up to the 5th postoperative day. A morphological, ultrastructural, and immunohistochemical analysis (CD31) was performed on each piece. Immunohistochemical analysis demonstrated significant protection on endothelium in group A compared to group B starting from the 1st observational day. Ultrastructural data confirmed immunohistochemistry. These preliminary results represent a basis for further analysis. They suggest the protective role of HTK solution in preserving endothelial integrity and may imply some clinical benefits in organ protection.

Bilateral internal thoracic artery grafting: long-term clinical and angiographic results of in situ versus Y grafts.

BACKGROUND: We evaluated whether bilateral internal thoracic arteries provide the same long-term results when used as in situ grafts and as Y grafts. METHODS AND RESULTS: From October 1991 to February 2000, 1818 patients had bilateral internal thoracic arteries used as in situ (n = 1378, group A) or as Y grafts (n = 440, group B). The number of anastomoses per patient and the number of bilateral internal thoracic artery anastomoses per patient were higher in group B (3.1 +/- 0.9 and 2.7 +/- 0.9) than in group A (2.9 +/- 0.8 and 2.2 +/- 0.6) (both P <.001). The number of right internal thoracic artery anastomoses per patient rose from 1.0 +/- 0. 3 in group A to 1.4 +/- 0.6 in group B (P <.001), and the number of sequential anastomoses per right internal thoracic artery graft rose from 4.1% to 34.3% (P <.001). Thirty-day mortality was 2.0% in group A versus 2.5% in group B (P = not significant). No difference in postoperative course was detected. Eight-year survivals were 95.8% +/- 2.7% in group A versus 94.8% +/- 4.0% in group B (P = not significant), and event-free survivals were 95.2% +/- 2.9% in group A versus 93.6% +/- 4.4% in group B (P = not significant). Early angiograms were obtained in 295 patients (945 anastomoses, 863 distal and 82 proximal Y grafts), 213 patients (611) in group A and 82 patients (334) in group B. Patency rate was 98.8% in group A and 96.0% in group B (P = not significant), whereas grade A patency rate was 97.2% in group A and 96.4% in group B (P = not significant). Late angiograms were obtained in 88 patients (25 in group A and 63 in group B) at a mean of 17.5 +/- 18.4 months: patency rate was 100% in group A and 99.2 in group B (P = not significant), and grade A patency rate was 98.6% in group A and 98.8% in group B (P = not significant). No Y anastomosis was occluded or stenosed. COMMENT: Survival, incidence of cardiac events, and angiographic patency in the early and late phases are similar for bilateral internal thoracic arteries used either in situ or as Y grafts. However, Y grafting with bilateral internal thoracic arteries increases the number of anastomoses per bilateral thoracic artery, as well as the flexibility of the right internal thoracic artery.

Midterm results after minimally invasive coronary surgery (LAST operation)

BACKGROUND: Our experience with a left internal thoracic artery graft to the left anterior descending artery via a left anterior small thoracotomy is reviewed to evaluate midterm results. METHODS: From November 1994 to April 1997, four hundred sixty patients were scheduled to undergo a left internal thoracic artery graft to the left anterior descending coronary artery via a left anterior small thoracotomy; 26 of these patients (5.7%) were converted and 434 of them had the operation. Two hundred fourteen patients (49.3%) had isolated disease of the left anterior descending artery, and 220 patients (50.7%) had multiple vessel disease. A sufficient length of the left internal thoracic artery was harvested to reach the left anterior descending artery. RESULTS: Three hundred nine patients (71.2%) underwent extubation by hour 2. Mean intensive care unit stay was 4.2 +/- 4.5 hours; mean postoperative hospital stay was 66 +/- 29 hours; the 30-day mortality rate was 1.1%; the late mortality rate was 1.4%. Eighteen patients underwent reoperation early (< or = 30 days), and eight patients underwent reoperation late (> 30 days) because of conduit/anastomotic malfunction. Four patients underwent reoperation with patent anastomosis for progression of disease (n = 3) or pericarditis (n = 1). Three patients had a percutaneous transluminal coronary angioplasty. Cumulating angiographic and stress Doppler flow assessment results, a patent anastomosis was obtained in 417 patients and a nonrestrictive anastomosis in 404 patients. Twenty-nine months after surgery, survival was 97.1% +/- 0.7% (95% confidence interval 90.5% to 100%) and event-free survival 89.4% +/- 1.2% (95% confidence interval 78.2% to 100%). In the last 190 patients, with our increased experience and better instruments, we obtained a patent anastomosis in 188 patients (98.9%) and a nonrestrictive anastomosis in 185 (97.4%). CONCLUSIONS: Left anterior small thoracotomy gives acceptable midterm results. Incidence of patent and nonrestrictive anastomoses was satisfactory, especially in the most recent part of our experience, when the learning curve ended.

Composite lengthened arterial conduits: long-term angiographic results of an uncommon surgical strategy.

BACKGROUND: We sought to evaluate the long-term patency rate of composite lengthened conduits. METHODS AND RESULTS: From December 1991 to April 2000, 43 patients had a composite lengthened arterial conduit. There was a mean of 2.83 +/- 1.23 anastomoses per patient. No 30-day mortality occurred. Five patients died from 3 to 84 months after the operation (mean, 38.6 +/- 34.6 months). After a mean follow-up of 57.0 +/- 32.3 months (range, 3-99 months), all the survivors are asymptomatic. The only cardiac major events recorded were 2 (4.6%) late acute myocardial infarctions in the patients who died. Eight-year survival and event-free survival were both 80.4% +/- 9.1% (range, 3%-93%). In the early period (13.5 +/- 4.8 days) in 26 patients, 26 arterial composite lengthened conduits and 37 distal anastomoses had postoperative angiographic control; all the anastomoses were rates as grade A, according to Fitzgibbon classification. In the late period (29 +/- 30 months) in 23 patients, 23 arterial composite lengthened conduits and 34 distal anastomoses were checked; the patency rate was 22 (95.6%) of 23 for the composite lengthened conduits and 33 (97%) of 34 for the distal anastomoses. CONCLUSIONS: In particular situations, when the length of an arterial conduit is not enough to allow a correct use of the graft, lengthening of an arterial conduit can be a safe and effective technique.

Early clinical experience with a new sutureless anastomotic device for proximal anastomosis of the saphenous vein to the aorta.

BACKGROUND: Avoiding aortic side clamping is useful to avoid local particulate embolization. A device that allows a saphenous vein graft to be anastomosed to the aorta without aortic manipulation is clinically evaluated. METHODS AND RESULTS: From July 1999 to March 2000, 17 patients who underwent myocardial revascularization had an aorta-saphenous vein graft anastomosis performed by means of an aortic anastomotic device. Eight were operated on with cardiopulmonary bypass and 9 without. The proximal anastomoses created by the aortic anastomotic device were performed before the institution of cardiopulmonary bypass or before the related distal anastomosis was performed. In 11 patients transcranial Doppler ultrasound was used. In 1 (6%) patient the saphenous vein graft was not deployed, and in 2 (12%) a single suture was added for minor bleeding. None of the 11 patients evaluated with transcranial Doppler ultrasound had evidence of particulate embolization during the procedure. No patient died or was reoperated on for bleeding. Six (35%) patients had a postoperative angiogram 48 +/- 26 days after the operation that showed widely patent proximal anastomoses. CONCLUSIONS: Use of an aortic anastomotic device allows a sutureless anastomosis to be created between the aorta and saphenous vein graft. The device could be used in totally endoscopic myocardial revascularization. A second-generation device is ready to solve the problems encountered and to increase the ease in handling the device.

Composite arterial conduits for a wider arterial myocardial revascularization.

From October 1991 to May 1993, 130 patients were submitted to myocardial revascularization using complex preformed arterial conduits. The age ranged from 29 to 75 years (mean age, 60.1 years); 121 patients were male. One hundred twenty-six patients had double- or triple-vessel disease. The mean ejection fraction was 0.53 (range, 0.22 to 0.79); only 6 patients had an ejection fraction less than 0.35. In 6 cases the procedure was a reoperation. We used 360 arterial conduits, 163 of which as free grafts (3 left internal mammary arteries, 16 right internal mammary arteries, 86 inferior epigastric arteries, 57 radial arteries, and 1 right gastroepiploic artery). One hundred fifty-four free grafts were anastomosed to one or both internal mammary arteries and one to a radial artery. We constructed 136 complex arterial conduits (branched, lengthened, or both). In 6 cases a double arterial system had to be used in a single patient. There was no operative mortality, and no inotropic or mechanical supports were used. The overall mortality rate was 1.5%. Early angiographic controls (between the 7th and 15th postoperative days) demonstrated 100% patency; late angiographic controls (at a mean interval of 9.5 months after operation) documented a mean patency rate ranging from 94.1% of the radial arteries to 100% of the left internal mammary arteries and right gastroepiploic arteries. At a mean follow-up of 7.2 months (range, 1 to 15 months) all patients are alive without recurrence of symptoms.

The LAST operation: techniques and results before and after the stabilization era.

BACKGROUND: Left anterior descending artery stabilization allows performance of left internal mammary artery grafting via a left anterior small thoracotomy on a beating heart. Our surgical experience was reviewed to assess if surgical results have improved as result of specialized instrumentation. METHODS: Of 545 patients who had the left anterior small thoracotomy operation, 261 underwent this procedure for single left anterior descending artery disease. Two groups were considered, before and after the use of specialized instrumentation: group A (n = 93), operated on from November 21, 1994, to April 20, 1996; and group B (n = 168), operated on from April 21, 1996, to December 1997. RESULTS: Early mortality was similar in the two groups. The further revascularization (operation or percutaneous transluminal coronary angioplasty) and the rate of occlusion of the conduit were higher in group A, whereas anastomotic or conduit malfunction was not. Cumulating angiography and Doppler flow evaluation, 92.5% of the anastomoses in group A and 98.8% in group B (p = 0.026) were patent, and 90.3% in group A and 97.6% in group B (p = 0.031) were patent and not restrictive. At 19 months, survival was similar, but the event-free survival was higher in group B. CONCLUSIONS: Both left anterior descending artery stabilization and safer left internal mammary artery harvesting contributed to improve angiographic and clinical results after the left anterior small thoracotomy operation.

Radial artery and inferior epigastric artery in composite grafts: improved midterm angiographic results.

BACKGROUND: The improving results with use of the radial artery and the inferior epigastric artery as coronary bypass conduits were analyzed to assess the suitability of these arteries for myocardial revascularization. METHODS: Both arteries were used in composite arterial conduits with an internal mammary artery as the blood source. The proximal anastomosis was always constructed before the initiation of cardiopulmonary bypass. From October 1991 to January 1995, 240 patients underwent myocardial revascularization using 163 radial arteries and 124 inferior epigastric arteries with one (224 instances) or both (two instances) internal mammary arteries as inflow conduits. Twenty-five saphenous veins were concomitantly used. There were 208 men and 32 women with a mean age of 60.8 +/- 8.6 years (range, 28 to 80 years). In 73 patients (30.4%), the operation was performed on an urgent basis, and in 11 (4.6%), it was a repeat operation. The mean left ventricular ejection fraction was 0.55 +/- 0.12, and in 21 patients (8.8%), it was less than 0.35. Of 681 distal anastomoses, 188 were constructed using the radial artery (35 double and one triple sequential anastomosis) and 125, using the inferior epigastric artery (one double sequential anastomosis). A mean of 3.0 arterial anastomoses per patient were constructed (3.1 anastomoses/patient including saphenous veins). Six patients (2.5%) underwent associated procedures: aortic valve replacement (2), carotid endarterectomy (2), mitral valve replacement (1), and aortic valve and ascending aorta replacement (1). Most of the inferior epigastric arteries were grafted on diagonal branches and most of the radial arteries, the circumflex territory. RESULTS: No deaths occurred in the operating room. Three patients (1.3%) died postoperatively, and 2 patients (0.8%) died 6 months after operation. At a mean follow-up of 18.5 +/- 10.4 months (range, 1 to 39 months), 227 patients (96.6%) were asymptomatic. The cumulative patency rate of the radial artery grafts was 93.1% and of the inferior epigastric artery grafts, 95.7%. CONCLUSIONS: Our data suggest that use of the RA and the IEA in composite conduits for myocardial revascularization is feasible. These arteries can be safely used when bilateral internal mammary artery or sequential internal mammary artery grafting is not advisable.

Intermittent antegrade warm blood cardioplegia.

Intermittent antegrade warm blood cardioplegia has been used routinely at our institution over the last 3 years. We report here a comparison between the first 250 consecutive patients undergoing elective coronary artery bypass grafting in which intermittent antegrade warm blood cardioplegia was used (group A) and the last 250 consecutive patients who received intermittent antegrade cold blood cardioplegia, during bypass grafting (group B). There were no differences in sex, age, number of grafts, and functional status between the two groups; left ventricular ejection fraction was lower in group A. The overall mortality rate in group A was 0.8% versus 3.6% in group B (p < 0.05). There was no in-hospital mortality among high-risk patients (ejection fraction < or = 0.35) in group A (0/53) versus two deaths in group B (2/28) (p < 0.05). No patient in group A needed circulatory assistance; 4 patients in group B received intraaortic balloon pumping. Only 1 patient in group A required inotropic support versus 20 patients in group B (p < 0.0005), and 5 patients in group A received lidocaine hydrochloride for ventricular arrhythmias versus 18 in group B (p < 0.01). The rates of myocardial infarction and stroke were not different between the two groups. The peak concentration of the myocardial-specific isoenzyme of creatine kinase were higher in group B in absolute value (51 +/- 30 IU/L) than in Group A (38 +/- 38 IU/L) (p < 0.0005) and in percent of total creatine kinase (8.2% +/- 4.1% versus 6.2% +/- 2.9%, respectively).

Minimally invasive coronary artery bypass grafting on a beating heart.

BACKGROUND: We reviewed our experience with left internal mammary artery (LIMA)-to-left anterior descending artery (LAD) anastomosis on a beating heart through a left anterior small thoracotomy. METHODS: This procedure was performed in 343 of 358 scheduled patients; in 15 (4.2%) the LAD was not suitable or was too small. The chest was opened in the fourth (127, 37.0%) or fifth (197, 57.4%) intercostal space, or both (19, 5.6%); the length of the harvested LIMA was 4-15 cm. The LAD was occluded by means of two 4-0 Prolene (Ethicon, Somerville, NJ) sutures, both snared on a small piece of silicone tubing. The anastomosis was performed with two 8-0 Prolene sutures. In the early postoperative period all patients underwent angiography or a doppler flow assessment of the LIMA or both. RESULTS: In 310 patients the LIMA was connected directly to the LAD; to elongate the LIMA, in 30 patients an inferior epigastric artery and in 3 patients a saphenous vein was used. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. Three patients (0.9%) died during the first 30 days after the operation, and 4 other patients (1.2%) died after the first month. Twenty-five patients (7.3%) were reoperated on because of anastomotic or conduit failure, 18 (5.2%) early and 7 (2.1%) late; one additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean of 9.5 +/- 5.7 months of follow-up, 336 patients (98.0%) were alive, asymptomatic with or without medical treatment, and without cardiac events. COMMENT: Left internal mammary artery-to-LAD anastomosis performed on a beating heart through a left anterior small thoracotomy is a procedure that can be performed with low risk and acceptable midterm results in selected patients.

Persistence of mammary artery branches and blood supply to the left anterior descending artery.

BACKGROUND: Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery. METHODS: Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 microg) was injected and the average peak velocities before and after injection were calculated. RESULTS: The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 +/- 7 and 26 +/- 5 cm/sec, respectively, in group A versus 27 +/- 5 and 25 +/- 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 +/- 0.3 in group A versus 0.69 +/- 0.3 cm/s in group B; p = NS), but not distally (1.72 +/- 0.1 in group A versus 0.97 +/- 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 +/- 0.6 and 2.5 +/- 0.3 cm/s, respectively, in group A versus 2.6 +/- 0.5 and 2.6 +/- 0.3 cm/s, respectively, in group B; p = NS). CONCLUSIONS: The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.

Bilateral internal mammary artery grafting: midterm results of pedicled versus skeletonized conduits.

BACKGROUND: To increase the number of anastomoses per patient, bilateral internal mammary arteries (BIMAs) were harvested with a skeletonized approach instead of a pedicled one. METHODS: One thousand one hundred forty-six patients underwent isolated myocardial revascularization using BIMAs, 304 receiving pedicled grafts (group A, October 1991 through May 1994) and 842 receiving skeletonized conduits (group B, June 1994 through June 1998). Group B had a higher incidence of patients with diabetes (223 versus 40, p < 0.001). RESULTS: The number of BIMA anastomoses per patient was significantly higher in group B (2.4 +/- 0.3 versus 2.1 +/- 0.4, p < 0.001), as well as the number of sequential grafts (288 versus 42, p < 0.001). Twenty-three patients (2.0%) died in the first 30 days after surgery, 5 in group A (1.6%) and 18 in group B (2.1%) (not significant). Postoperative complications were similar in both groups; the incidence of sternal wound healing problems was higher as a whole and with regard to diabetic patients (4 of 40 [10%] versus 5 of 223 [2.2%], p < 0.05) in group A. Seventy-one patients in group A and 133 (15.8%) in group B underwent a postoperative angiography. Patency rate was similar, both early (100% in group A versus 98.6% in group B, not significant) and late (98.6% in group A versus 98.4% in group B, not significant). CONCLUSIONS: The use of skeletonized BIMA conduits allowed us to increase the number of BIMA anastomoses per patient with a lower rate of sternal wound complications and angiographic results similar to those obtained with pedicled BIMA conduits.

Multiple arterial conduits without cardiopulmonary bypass: early angiographic results.

BACKGROUND: Lack of angiographic results and technical difficulty in grafting the vessels in the lateral and posterior walls have reduced interest in myocardial revascularization without cardiopulmonary bypass (CPB). We describe our experience to demonstrate the feasibility of coronary surgical intervention without CPB in multivessel disease. METHODS: From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients. RESULTS: Mean +/- SD anastomoses per patient were 2.5 +/- 0.6 in group A and 2.8 +/- 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 +/- 7.1 versus 27.3 +/- 36 hours, p < 0.001, and 4.1 +/- 1.6 versus 5.4 +/- 2.4 days, p < 0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 +/- 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches). CONCLUSIONS: Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.

Minimally invasive mammary artery Doppler flow velocity evaluation in minimally invasive coronary operations.

BACKGROUND: Left internal mammary artery Doppler flow velocity assessment during the Azoulay maneuver (patient's legs are passively lifted up and actively maintained by the patient) can increase the information on the anastomosis quality after left internal mammary artery to left anterior descending coronary artery grafting after the left anterior, small thoracotomy operation. METHODS: One hundred patients had an early postoperative angiography and a Doppler flow velocity assessment at rest and during the Azoulay maneuver. Peak and mean systolic velocities, peak and mean diastolic velocities, and peak and mean diastolic to systolic velocity ratios were recorded in all patients. RESULTS: In 95 patients with no restrictive conduit or anastomosis, peak and mean diastolic to systolic velocity ratios increased during the Azoulay maneuver; all but 1 patient showed at least one ratio equal to or greater than 1. In 4 patients with restrictive conduit or anastomosis, peak and mean diastolic to systolic velocity ratios were always less than 1 during the Azoulay maneuver. In the patient with an occluded conduit these ratios were less than 0.6. CONCLUSIONS: Peak and mean diastolic to systolic velocity ratios less than 1 during the Azoulay maneuver are suggestive of conduit or anastomosis malfunction. If we limit the angiographic controls to these patients, it is very likely that a pathologic anastomosis or conduit will not be missed.

Off or on bypass: what is the safety threshold?

BACKGROUND: To identify the technical profile of the patients operated on without cardiopulmonary bypass (CPB) and the benefit of the procedure. METHODS: From May 21, 1997, to December 31, 1998, 785 patients had coronary artery bypass grafting through a median sternotomy (group A: 472 without CPB; group B: 290 with CPB; group C: 23 converted). Technical aspects, mortality rate, cerebrovascular accident (CVA) incidence (crude and risk-adjusted), and incidence of major complications were recorded. RESULTS: Patients without CPB had mainly one to three grafts and one- or two-vessel disease. Multiple arterial grafting was not a limit, whereas sequential grafting was. Group A had lower complications rates, shorter intensive care unit and postoperative in hospital stays, and lower transfusion rates. Mortality rates and CVA incidence (crude and risk-adjusted) were similar in both groups and in each subgroup considered. In group A, a lower complications rate was present in some patients (aged greater than 70 years, female, with unstable angina). Group C showed higher mortality and complications rates. Failure of revascularization showed no difference between groups. CONCLUSIONS: Primary endpoints are not affected by the surgical strategy, whereas some of the secondary endpoints are. However, patients in group A experienced fewer complications. Both techniques can give satisfying results and must be applied according to the surgeon's preference.

Mitral valve procedure in dilated cardiomyopathy: repair or replacement?

BACKGROUND: Mitral valve (MV) procedure for dilated cardiomyopathy is becoming popular. We analyzed the indications to MV repair or replacement according to our 10-year experience. METHODS: From January 1990 to May 2000, 49 patients with dilated cardiomyopathy (12 idiopathic and 37 ischemic) underwent MV operation, 29 repair and 20 replacement. Preoperative evaluation included measurement of MV coaptation depth (CD) as a mirror of the abnormalities of MV apparatus leading to functional mitral regurgitation. RESULTS: Thirty-day mortality was 4.2% (2 patients). One-, 3-, 5-, and 10-year actuarial survival was, respectively, 90%, 87%, 78%, and 73%. The possibility of survival with at least one New York Heart Association functional class improvement was 88%, 76%, 71%, and 65%. Return of functional mitral regurgitation after MV repair was nearly inevitable; however, using a scale from 0 to 4, mean postoperative functional mitral regurgitation was 1.2+/-0.8 when preoperative MVCD was 10 mm or less and 2.5+/-0.7 when preoperative MVCD was 11 mm or higher (p < 0.05). Globally, functional results were not influenced by the strategy of treatment (MV repair or replacement). CONCLUSIONS: Mitral valve operation can give satisfying survival and good palliation of dilated cardiomyopathy. The MVCD can be helpful in the choice of the surgical strategy on the MV.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome.

BACKGROUND: The impact of myocardial revascularization without cardiopulmonary bypass (CPB) was evaluated in a series of consecutive patients with multivessel disease. METHODS: From May 21, 1997 to November 30, 2000, 1,843 consecutive patients underwent isolated myocardial revascularization. From this total, 919 patients were done without CPB (group A, 49.9%) and 924 patients were done with CPB (group B, 50.1%). Patients that converted from without CPB to with CPB were included in group A. Thirty-three variables were evaluated with univariate and multivariate analysis to identify the independent variables predictive of higher incidence of early mortality, acute myocardial infarction, cerebrovascular accident, and early major events. RESULTS: Early mortality was 2.2% (group A, 1.4%; group B, 3.0%; p = 0.016), acute myocardial infarction incidence was 1.8% (group A, 1.1%; group B, 2.6%; p = 0.027), cerebrovascular accident incidence was 0.9% (group A, 0.8%; group B, 1.0%; p = not significant), and early major events incidence was 6.7% (group A, 5.3%; group B, 8.2%; p < 0.001). Stepwise logistic regression analysis showed that CPB was an independent risk factor for higher mortality (odds ratio, 2.2; p = 0.0217), higher incidence of acute myocardial infarction (odds ratio, 2.5; p = 0.0185), and higher incidence of early major events (odds ratio, 1.8, p = 0.0034). CONCLUSIONS: When CPB was not used, patients experienced lower early mortality and incidences of acute myocardial infarction were less complicated, both at univariate analysis and stepwise logistic regression analysis.

Radial artery for myocardial revascularization: long-term clinical and angiographic results.

BACKGROUND: To evaluate the long-term clinical and angiographic results of the radial artery (RA) as a graft in coronary artery bypass surgery. METHODS: One hundred sixty-four patients had a RA graft from July 1992 to July 1994. In 128 (group A) the RA was connected end to side (115) or end to end (13) to the left internal mammary artery. In 36 (group B) the proximal anastomosis was on the ascending aorta. RESULTS: Early mortality was 1.8% (group A 1.6% and group B 2.8%). Eight-year survival was 83.2%+/-3.2% (group A 82.1%+/-3.8% and group B 86.7%+/-6.2%, p = not significant [NS]), and event free survival was 80.1%+/-3.5% (group A 79.9%+/-4.4% and group B 80.2%+/-7.3%, p = NS). Sixty-one patients (37.2%) had an early angiography within 90 days from the operation. Patency rate of RA distal anastomoses were 98.9% (88 of 89), 98.7% in group A (77 of 78), 100% in group B (11 of 11; p = NS). After a mean of 48+/-27 months (6 to 96), 72 patients (51.1% of the survivors) had a new angiography. Patency rate of RA distal anastomoses was 95.6% (87 of 91), 93.8% in group A (61 of 65) and 100% in group B (26 of 26; p = NS). All the intermediate RA-LIMA anastomoses were patent at the early and late control. Patency rate for RA and IMAs was similar both early (88 of 89 versus 82 of 82; p = NS) and after 48+/-27 months (87 of 91 versus 93 of 93; p = NS). CONCLUSIONS: Long-term clinical results after RA grafting are satisfying. Angiographic patency rate, both early and after 48 months, is higher than 90% and is similar to that obtained with internal mammary arteries. The site of the proximal anastomosis does not influence early and late patency.

Complete revascularization with three or more arterial conduits.

A complete revascularization with three or more arterial conduits was achieved, giving the patient, if possible, three blood sources from the in situ arterial grafts (skeletonized bilateral internal thoracic arteries [ITAs] and right gastroepiploic artery). If one of these conduits was not available, a radial artery was used, the proximal anastomosis being constructed on an ITA. The inferior epigastric artery was used if a sequential anastomosis was not advisable or to lengthen another arterial graft. With this strategy, 247 patients underwent surgery from October 1991 through April 1995; 774 arterial conduits were used: 244 left ITAs, 187 right ITAs, 159 right gastroepiploic arteries, 114 radial arteries, and 70 inferior epigastric arteries. The in-hospital and late mortality rates were 1.2% (3 patients) and 1.6% (4 patients), respectively. Of the 240 patients alive, 235 (97.9%) are asymptomatic. We compared the 42-month survival and event-free survival curves of these patients with those of an historical cohort of patients who underwent surgery with mixed (1 left ITA and saphenous vein grafts) revascularization. Whereas the survival rate was similar (97.82% +/- 1.11% vs 99.35% +/- 0.65, P = .174), the event-free survival rate was significantly better in the total arterial group (93.72% +/- 2.1 % vs 85.62% +/- 2.84%, P = .021). We conclude that complete revascularization with three or more arterial conduits is technically feasible with a low mortality rate; the mid-term results allow us to continue this strategy of myocardial revascularization.

Minimally invasive coronary artery surgery: the last operation.

Left anterior descending grafting with a left internal thoracic artery on a beating heart via a small left anterior thoracotomy is a procedure that is becoming popular, even if not yet standardized. From November 21, 1994 through February 20, 1997, 411 patients underwent a small left anterior thoracotomy; 206 had single-vessel disease, 205 had multiple-vessel disease. The early mortality rate was 1.0% (4 patients); causes of death were cardiac, not operation-related in 3, and non-cardiac in 1. The late mortality rate was 1.4% (6 patients); causes of death were cardiac operation-related in 1, non-cardiac in 3. All patients had a postoperative Doppler-flow velocity assessment; 231 (56.2%) underwent an angiographic control during the first postoperative year. Some patients were selected, as every patient with conduit or anastomotic malfunction underwent angiography. The patency rate was 92.4% (214/231); perfect distal anastomoses were obtained in 87.0% (201/231). With increasing experience and new instruments for left internal thoracic artery harvesting and left anterior descending artery stabilization, from April 21, 1996, patency rate increased to 98.2% (107/109) and perfect patency rate to 95.4% (104/109); results are therefore improving with time. The left anterior small thoracotomy procedure gives acceptable midterm results and is a reasonable alternative to the median sternotomy when the left anterior descending artery needs to be grafted with the left internal thoracic artery.