Ann M. Emery

Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging

Minimally invasive direct coronary artery bypass grafting offers mortality and morbidity advantages to selected patients. To broaden indications for such, an appropriate and combined disciplinary approach using angioplasty and minimally invasive direct coronary artery bypass grafting is described in a patient requiring reoperative grafting. Documentation of patency of new left internal mammary artery-to-left anterior descending artery anastomoses performed without the use of cardiopulmonary bypass was obtained intraoperatively using a Thermal Imaging Camera.

Minimally invasive direct coronary artery bypass grafting : Experimental and clinical experiences

BACKGROUND This communication briefly details the goals, indications, surgical approaches, and limitations of minimally invasive direct coronary artery bypass grafting (MIDCABG). The experimental experiences from various institutions are summarized. METHODS The clinical experiences of 72 consecutive MIDCABG procedures performed at our institutions between June 5, 1995, and August 13, 1996, were analyzed. We have divided patients into two groups. Group A consists of healthy low-risk patients with single lesions of the left anterior descending coronary artery or the right coronary artery, or with both lesions of both arteries. Group B consists of high-risk patients who had major contraindications to conventional cardiopulmonary bypass procedures. There were 55 patients in group A and 17 patients in group B. Using The Society of Thoracic Surgeons preoperative predicted risk module, group A had a 1% predicted mortality versus 4% in group B. RESULTS The 30-day mortality was 2% in group A and 6% in group B. The mean postoperative length of stay was 4 days for group A and 5 1/2 days for group B. Short-term follow-up of the survivors appears promising, and 81% of patients were angina free at the time of last follow-up. CONCLUSIONS The MIDCABG techniques are still developing. The short-term results during the learning period appear to be quite good, but long-term results remain yet to be seen. The addition of new equipment to facilitate construction of the anastomosis will enhance application and results. The lessons learned from these approaches are already being applied to other areas of cardiac surgery including valve replacement and the repair of congenital heart defects.

Anticoagulation for mechanical heart valves: a role for patient based therapy

Anticoagulation management issues following mechanical cardiac valve replacement revolve around target levels for chronic oral anticoagulation. While these levels are important, they are only one aspect of a follow-up process that should be individualized to each patient with a mechanical cardiac valve and coupled with patient education, risk factor modification, and long-term follow-up. It is difficult to separate patient related risk factors, those traditional risk factors that markedly increase the incidence of potential valve related events (i.e., atrial fibrillation), and yet other more subtle non-traditional risk factors for thromboembolism (i.e., smoking and hypertension) that contribute to events. These also require management during the post-operative period and long-term follow-up. There are also different risk factors for anatomic valve position. The aortic valve is the safest of all the anatomic positions regarding valve related events. The mitral valve is at higher risk and the tricuspid valve is the most risky anatomic position. Anticoagulation related hemorrhage is the most dangerous event for mortality and morbidity in the aortic position, thromboembolism in the mitral position, and valve thrombosis in the tricuspid position. Each of these requires different degrees of patient modification and target levels for anticoagulation. Additionally, low risk patients with aortic valve replacement may not require anticoagulant therapy at all. Rather, treatment with modern, highly potent platelet inhibiting drugs may be effective after a period of sewing ring endothelialization under the protection of antithrombotic therapy. Each of these aspects and risk factors is discussed, as well as the call for prospective randomized trials treating low risk patients with anti-platelet drugs versus warfarin anticoagulation.

Use of peripheral ultrafiltration in the postoperative cardiac surgery patient.

Background After cardiac surgery, most patients have development of third-space fluid retention, commonly treated with diuretics. In some patients diuretics are ineffective. In this subset, a simplified system for ultrafiltration was used for fluid extraction. Methods After obtaining permission from the institutional review board, the hospital charts of the first 30 patients having ultrafiltration were retrospectively reviewed to abstract data on fluid extraction and patient outcomes. Data are expressed as mean ± standard deviation. Results From April 2004 through January 2006, 30 patients were selected for ultrafiltration. In one patient, adequate intravenous access could not be obtained. There were 11 female and 18 male (age, 69 ± 12 years) postoperative cardiac surgery patients. The mean ultrafiltration run was 10.5 ± 9 hours, resulting in fluid extraction of 3528 ± 2111 mL per run and 5596 ± 3870 mL per patient (11 patients had more than 1 run). Hospital stay was 9.4 ± 4.4 days. Three patients died unrelated to ultrafiltration. Conclusions Ultrafiltration as an alternative means of fluid extraction in postoperative cardiac surgery patients was effective and well tolerated.

Complete revascularization on cardiopulmonary bypass: a closer look at existing technology

During the 1990s, two significant advancements altered the thinking on the surgical treatment of coronary artery disease. The first is the documentation that complete arterial revascularization further improves patients survival, increases the symptom free interval and decreases the incidence of reoperation as compared to saphenous vein grafting with and without left internal mammary artery grafting [1‐5]. This concept is an evolution in the ongoing development of the treatment of ischemic heart disease. Moreover, life span is prolonged by coronary interventional therapy only if the internal mammary artery bypass to the anterior descending coronary artery is performed [6]. When coupled with completeness of revascularization utilizing arterial conduits, including the radial artery, gastroepiploic artery and one or two mammary arteries, further longevity can be predicted [4]. Arterial conduits are of consistent quality whereas saphenous veins are variable. Saphenous vein diameter, wall thickness and status of the valves differ among patients. In females and the elderly, veins may be fragile or may contain significant disease such that they become substantively inert conduits. In patients with severe varicose veins, early occlusion can be expected. Predictors of the development of vein graft disease are not well delineated. Other venous conduits, including the cephalic vein, have demonstrated poor long-term patency. Decision making regarding the choice of conduit influences the conduct of the operation proposed for the patient. Secondly, but not less important, is the development of

Minimally invasive direct coronary artery grafting (MIDCAB)

A program for minimally invasive surgery for Cardiac Surgical Associates was initiated by K. V. Arom and R. W. Emery but had the broad shoulders of Dr. Nicoloff to lend support in this very controversial field. The efforts of our Research Division were essential to establishing a credible program. It was their role to obtain informed consent (when we began our initial series), perform detailed chart review and data collection, and to follow up our patients as carefully as possible for one year. Five other of our associates have since trained in and are part of the continuing development of a MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) surgery program. They are doctors Theodore Lillehei, Thomas Flavin, John Teskey, William Northrup and Vibhu Kshettry.