Amihay Shinfeld

Right ventricular outflow tract reconstruction: valved conduit of choice and clinical outcomes.

Background The valved conduit of choice in right ventricular outflow tract (RVOT) reconstruction provides a challenge for cardiac surgeons. The present study collected data regarding the clinical outcome of valved conduits for RVOT reconstruction, so as to explore various options of ideal conduits in clinical practice. Methods English language articles on valved conduits for RVOT reconstruction were retrieved from the MEDLINE database with respect to the commonly used homograft, stented xenograft and stentless xenograft, and the occasionally used autologous tissue valved conduit as well. Clinical outcomes of each conduit were outlined with respect to their early and late mortalities, conduit failure, conduit reoperation, reoperation-free interval, actuarial freedom from reoperation, and survival rates. Conduit-related complications, risk factors and pathological findings of the valved conduits were summarized. Results Conduit failure was defined as the need for reoperation for conduit stenosis or extrinsic compression, conduit regurgitation, or anastomotic dehiscence. The conduit failure rates at 2 years were 9–55%, 35% and 25% for homograft, stented xenograft and stentless xenograft conduits, respectively. The 5-year actuarial freedoms from reoperation were 87–98.2% for homograft, 37% for Hancock, 81–92% for Carpentier–Edwards, 78% for Contegra, and 82.95% for LabCor, respectively. The result for Hancock at 5 years appeared to be disappointing, although it did prove promising, and was 79.5% at 10 years and 65.8% at 15 years. Autologous pericardial valved conduits for RVOT reconstruction showed superb properties, and the autologous monocusp pulmonary artery conduit functioned well early postoperatively, but data for long-term follow-up are lacking. Conclusion Conduit failure and explant is inevitable. This phenomenon is worse with a longer follow-up. Mechanisms involved in conduit failure are unknown, even though they were accounted for by calcification and extensive intimal proliferation, and somatic outgrowth. Homografts are commonly used and have experienced a long history. The pulmonary homograft is the most commonly used RVOT conduit, especially in small children, due to its excellent characteristics. The newly-developed Contegra conduit has become popular due to its availability in full sizes and the acceptable results obtained at intermediate follow-up. The Hancock conduit can function sufficiently well for as long as 5–10 years, and early valve failure is relatively rare. It is admissible to use the Hancock conduit as an interim measure for future conduit reoperation due to its adequate function until subsequent operation. The application of an autologeous tissue valved conduit should be considered when other alternatives are not available.

Postoperative pain trajectories in cardiac surgery patients.

Poorly controlled postoperative pain is a longstanding and costly problem in medicine. The purposes of this study were to characterize the acute pain trajectories over the first four postoperative days in 83 cardiac surgery patients with a mixed effects model of linear growth to determine whether statistically significant individual differences exist in these pain trajectories, and to compare the quality of measurement by trajectory with conventional pain measurement practices. The data conformed to a linear model that provided slope (rate of change) as a basis for comparing patients. Slopes varied significantly across patients, indicating that the direction and rate of change in pain during the first four days of recovery from surgery differed systematically across individuals. Of the 83 patients, 24 had decreasing pain after surgery, 24 had increasing pain, and the remaining 35 had approximately constant levels of pain over the four postoperative days.

Multidisciplinary intervention for control of diabetes in patients undergoing coronary artery bypass graft (CABG)

In Israel, as elsewhere, diabetes mellitus is highly prevalent among patients undergoing coronary artery bypass graft (CABG). The bulk of evidence, derived retrospectively, suggests that poor control of diabetes predisposes to complications of CABG and increases mortality; but the findings in a number of studies fail to support that impression. Anticipating a prospective investigation designed to resolve this issue, we have carried out a preliminary study of 147 consecutive patients with diabetes who were hospitalized for elective CABG during 1998. Our objective was to determine how well and how often diabetes could be controlled in accordance with selected metabolic goals in the brief interval between hospital admission and surgery and during the operation itself and in the postoperative period. The task was undertaken by a multidisciplinary team, in cooperation with the Department of Cardiac Surgery. The metabolic goals were: fasting blood glucose consistently between 65-140 mg/dl before and after surgery and 120-180 mg/dl at the time of surgery; and postprandial blood glucose consistently <180 mg/dl. These goals were achieved in 18.1% of fasting blood glucose measurements before and after surgery, 22.1% of preprandial and 14.6% of postprandial blood glucose levels consistently <180 mg/dl. There were no clinical episodes of hypoglycemia. Due to the low incidence of major infection related complications (deep sternal wound infection in only 3 patients (2.0%)) no significant statistical conclusions on the relations between glucose control and these complications could be drawn. The means of all values of FBG and of hemoglobin A1c were significantly higher among patients with complications (n=49) than in those without (P=0.01).

Risk of Aortic Dissection in Pregnant Patients With the Marfan Syndrome.

Patients with Marfan syndrome (MS) face a high risk of aortic dissection during pregnancy. A dilated aortic root (>40 to 45xa0mm) is considered a relative contraindication for pregnancy. We investigated the risk for aortic dissection and pregnancy outcome in patients with MS. Women with MS who attended our cardiology high-risk pregnancy clinic from 2006 to 2015 were followed clinically and with serial echocardiograms by a multidisciplinary team. Beta blockers were offered and titrated by blood pressure and heart rate. Patients with aortic root dilation ≥40xa0mm were considered high-risk patients with MS. A consistent increase in aortic root diameter of >1xa0mm during pregnancy was classified as dilation during pregnancy; 31 pregnancies in 19 patients with MS were followed. Four pregnancies were terminated early because of prenatal diagnosis of fetal MS and 4 additional babies born with MS. Eight pregnancies were in patients with a dilated aortic root (40 to 46xa0mm); 21 patients (68%) were treated with β blockers. There were 2 cases of postpartum aortic dissection (6.5%): 1 type A dissection in a woman with a dilated aortic root who declined β blockers (1 of 8, 12.5%) and 1 type B dissection. Increasing aortic root diameter (>1xa0mm) in pregnancy was significantly associated with later aortic dissection (2 of 6 vs 0 of 21, pxa0= 0.04). No maternal deaths occurred. All high-risk women with MS gave birth by cesarean section, whereas in the non-high-risk group mode of delivery was by obstetric indication. Preterm delivery rate was 41% (11 of 27). One antenatal fetal death and no major neonatal morbidity or mortality were observed. In conclusion, pregnant patients with MS, especially those with a dilating aortic root, are at high risk of aortic dissection, even with tight control of blood pressure and heart rate.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon.

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Configurations and classifications of composite arterial grafts in coronary bypass surgery.

The aim of this review is to present the configurations and classifications of composite arterial grafts in coronary bypass surgery. Articles were collected by tracking references cited in the literature with regard to the configurations of composite arterial grafts in coronary bypass surgery. Figures of the configurations were drawn in accordance to the schematic drawings, angiograms, photographs, table contents or written captions of the literature. According to their structural nature, composite arterial grafts can be classified as: (i) alphabetical (Y, T, I, U, K, X and H) and (ii) complex grafts (TY, loop, π and sling grafts). According to the conduits that form the composite graft, they can be classified as: (i) definite (all standard alphabetical grafts, classic π and sling grafts); (ii) varying [internal mammary artery (IMA) loop, modified π graft]; and (iii) indefinite conduit graft (TY graft). According to their application in coronary artery bypass grafting (CABG), they can be divided into complete arterial revascularization for: (i) triple vessel disease (T, Y, K, X, TY, π and sling grafts); (ii) two vessel disease (U, right Y, and two-thirds right IMA T grafts); and (iii) single vessel disease, mainly the left anterior descending artery with or without the diagonal branch (H, I, IMA loop and left IMA T grafts). According to the CABG method, they can be classified as: (i) for conventional CABG (sling graft); (ii) for minimally invasive direct coronary artery bypass (H graft); and (iii) for both conventional CABG and off-pump coronary artery bypass (T, Y, U, K, I, TY, IMA loop, and π grafts). Standard Y and T grafts have been accepted as the common figurations of composite arterial grafts to maximum graft length for the bypass of triple vessel disease. Composite arterial grafts overcome the limited availability of arterial conduits for performing total arterial myocardial revascularization, allow a gain in conduit length, and minimize the ascending aorta manipulation.

Mild increase in coronary sinus pressure with coronary sinus reducer stent for treatment of refractory angina.

Mild increase in coronary sinus pressure with coronary sinus reducer stent for treatment of refractory angina

Long-term Arm Morbidity after Radial Artery Harvesting for Coronary Bypass Operation

BACKGROUNDnThe use of the radial artery (RA) in coronary bypass operations has become increasingly popular in recent years, but there is almost no documentation regarding the midterm and long-term arm complications.nnnMETHODSnBetween January 1 and December 31, 1998, 109 patients underwent operations for myocardial revascularization employing a pedicled RA as 1 of the coronary grafts. The patients were surveyed for subjective arm morbidities at 2 times during their follow-up: short term (mean, 7 months postoperatively; range, 0.3-14 months) and long term (mean, 49 months postoperatively; range, 46-57 months).nnnRESULTSnAt the short-term follow-up, 33 (33.3%) of the patients had some complaints regarding the arm that was operated on, with 4 (4%) of the patients reporting arm disability with complaints that focused on pain (11, 11%), numbness (15, 15%), and parasthesias (12, 12%). At the longterm follow-up, only 9 patients (10.5%) still experienced some sort of inconvenience with the arm that was operated on, with 1 case of functional disability, 4 complaints (4.6%) of residual parasthesias, and 1 report (2.3%) each of pain or numbness. All but 2 of the patients with complaints at the short-term follow-up reported amelioration of symptoms at the long-term follow-up.nnnCONCLUSIONnIt appears that severe arm disability early after RA harvesting is likely to dissolve with time. Our favorable late follow-up results support the continuation of the employment of the RA as a conduit for coronary artery bypass grafting operations.

Irradiation of Fresh Whole Blood for Prevention of Transfusion‐Associated Graft‐versus‐Host Disease Does Not Impair Platelet Function and Clinical Hemostasis after Open Heart Surgery

Since our previous studies suggested that the transfusion of 1 unit fresh whole blood (FWB) after cardiopulmonary bypass (CPB) using a bubble oxygenator may provide hemostatic benefit equivalent to 8–10 units of platelet concentrates, we have routinely used FWB at the termination of CPB. Two patients who received FWB and developed transfusion‐associated graft‐versus‐host disease (TA‐GVHD) prompted us to investigate the effect of irradiation of FWB on platelet and clinical hemostasis. Twenty‐four patients were randomized to receive either 1 unit FWB (12 patients), or 1 unit irradiated FWB (IrFWB, 1,500 cGy, 12 patients) after CPB. Platelet aggregation on extracellular matrix, studied by a scanning electron microscope and graded from 1 to 4 (from poor to excellent aggregation), was similar in both groups preoperatively [3.3±0.9 (FWB) and 3.5±0.5 (Ir FWB)], and at the end of CPB [1.8±1.2 (FWB) and 1.9±0.9 (IrFWB)]. Platelet aggregation was similar after transfusion of FWB (3.0±1.0) and after IrFWB (3.2±0.8), as was the increase in platelet count. Twenty‐four hours total postoperative bleeding was similar (560±420 and 523±236 ml for FWB and IrFWB, respectively). We conclude that irradiation of FWB for prevention of TA‐GVHD does not impair platelet aggregating capacity, and can be used when blood is donated by the patients next of kin.

Ventricular Tachycardia Radiofrequency Ablation with Extracorporeal Membrane Oxygenation

Introduction: Cases of ventricular tachycardia (TV) with hemodynamic compromise present a challenge in achieving non-inducibility by radiofrequency catheter ablation (RFCA). We report our experience of VT RFCA facilitated by elective mechanical circulatory support. nMethods and results: Five patients with hemodynamically unstable, recurrent ventricular arrhythmias that were unresponsive to medical therapy underwent extracorporeal membrane oxygenation (ECMO) assisted RFCA of scar related VT. All underwent RFCA under general anesthesia and were connected to an ECMO circuit maintained at minimum flow of 1.5 L /min. In case of VT or VF the blood flow of the ECMO circuit was increased to 4 L/min to allow hemodynamic stability and adequate systemic organ perfusion. A total of 8 VTs were observed. In 4 cases, we mapped during VT the critical isthmus was found and ablated. Four VTs were targeted by substrate mapping only. Complete success, defined as non-inducibility with aggressive program stimulation of any VT, was achieved in 4 patients. In a single patient, a non-clinical VT was still inducible. He died of septic shock 24 hour after the procedure. The remaining 4 were free of ventricular arrhythmia as proven by implanted defibrillator interrogation, over a median follow up of 16 months. nConclusion: ECMO implantation for VTRFCA is safe and assists in reaching the desired endpoint of noninducibility. This approach should be considered in high risk patients who may not otherwise tolerate such procedures.