Atsushi Amano

Skeletonized radial artery grafting: improved angiographic results

BACKGROUNDnThe radial artery has been used for coronary artery bypass grafting (CABG) but its early angiographic results were relatively inferior to that of the internal mammary artery, most likely due to spasm of the graft. To avoid vasospasm we harvested the radial artery using a skeletonized technique and spasm was completely reversed before use. The graft patency of the skeletonized radial artery was compared with the radial artery graft harvested as a pedicle.nnnMETHODSnA total of 112 patients underwent isolated CABG using a pedicled radial artery between September 1, 1999, and August 31, 2000 (group P), and a total of 131 patients with a skeletonized radial artery between September 1, 2000, and August 31, 2001 (group S). An ultrasonic scalpel (Harmonic Scalpel; Ethicon EndoSurgery, Cincinnati, OH) was used for skeletonization and removing satellite veins and surrounding tissue. CABG was performed by the standard technique. Perioperative results were prospectively collected and compared between the two groups. Early angiographic results performed within 3 months were also compared.nnnRESULTSnThere were two hospital deaths in group S. Major complications were observed in 11 (8.4%) in group S and 3 (2.7%) in group P (p = not significant [NS]). None were related to the radial artery graft. Angiography was obtained in 96 patients of group S and 76 patients in group P and revealed that the stenosis free graft patency rate of group S (138 of 143, 96.5%) was superior to that of group P (73 of 86, 84.9%) with p < 0.005.nnnCONCLUSIONSnSkeletonization of the radial artery with the ultrasonic scalpel is safe and contributes to reducing the incidence of early graft stenosis.

Efficacy of off-pump coronary artery bypass grafting for the patients on chronic hemodialysis.

OBJECTIVEnCoronary artery bypass grafting (CABG) under a beating heart is reported to be less invasive and promise earlier recovery. This study was performed to evaluate the efficacy of off-pump CABG in patients with end-stage renal failure.nnnMETHODSnIsolated CABG was performed on 40 hemodialysis patients at Shin-Tokyo Hospital Group between September 1, 1993, and December 31, 2000. Among them, off-pump CABG was performed in 16 and on-pump CABG in 24. Their preoperative, perioperative, and follow-up data were retrospectively collected.nnnRESULTSnPatients demographics and coronary risk factors were similar in off-pump and on-pump groups. The mean number of bypass grafts was 1.9 +/- 1.1 in the off-pump group and 2.8 +/- 1.1 in the on-pump group (P < 0.05). Blood transfusion was significantly less frequent in the off-pump group than in on-pump group. Postoperative complications were more frequently observed in the on-pump group (7.1% off-pump vs 25.0% on-pump). There were two hospital deaths in the on-pump group and none in the off-pump group. Postoperative intubation time, ICU stay, and hospital stay were significantly shorter in the off-pump group than in the on-pump group. Although follow-up period was short (1.1 +/- 0.7 years), no cardiac events occurred in the off-pump group.nnnCONCLUSIONSnOff-pump CABG for hemodialysis patients is safe and useful and it enables early recovery. Postoperative cardiac events were controlled effectively during the short period of follow-up.

Urgent off-pump coronary artery bypass grafting.

OBJECTIVESnThe use of off-pump coronary artery bypass grafting (CABG) has become widespread, since it has proven less invasive and to promote early recovery. In this study, we investigated the efficacy of off-pump CABG in patients in the evolving phase of acute myocardial infarction.nnnMETHODSnRetrospective chart review was carried out for patients undergoing urgent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital Group between January 1991 and June 2001. The patients demographic, operative data, and postoperative results were collected.nnnRESULTSnThe off-pump group consisted of 19 males and 11 females with a mean age of 72.0 years and the on-pump group of 91 males and 38 females with a mean age of 64.3 years. Preoperative use of intraaortic balloon pumping and preoperative shock was more frequently observed in the on-pump group. The mean number of distal anastomoses was 3.1 +/- 0.9 in the off-pump group and 3.2 +/- 1.1 in the on-pump group (p = NS). Intubation time (18.5 vs 32.9 hours), ICU stay (3.4 vs 4.9 days), and postoperative stay (13.5 vs 24.3 days) were significantly shorter in the off-pump group than in the on-pump group (P < 0.05). The frequency of the major complications was significantly lower in the off-pump group (9/30, 30%) than the on-pump group (65/129, 50.4%), especially for postoperative low output syndrome (p < 0.05). Multivariate analysis demonstrated a significant reduction in the recovery period by use of off-pump CABG. Early follow-up results were similar between the two groups, in terms of late cardiac events and survival.nnnCONCLUSIONnUrgent off-pump CABG is safe and provides early recovery, provided that the patients intraoperative hemodynamics are taken into account.

Coronary artery bypass grafting for patients with poor left ventricular function.

Patients undergoing isolated first-time elective coronary bypass surgery were classified according to their preoperative ejection fraction: group 1 comprised 131 patients with poor left ventricular function (ejection fraction < 40%); group 2 was 1,496 control patients. The mean number of distal anastomoses was not significantly different in the 2 groups, however, clamp time, pump time, and operative time were longer in group 1. Patient recovery was significantly slower in group 1. Morbidity (14.5% in group 1 versus 7.4% in group 2, p < 0.005) and mortality (2.3% versus 0.1%, p < 0.0001) were higher in group 1. During late follow-up, the 5-year survival rate (70.1% versus 90.5%) and 5-year event-free rate (65.6% versus 81.9%) were significantly inferior in group 1 compared to group 2. The results of bypass surgery in cases of decreased left ventricular function were poor, and such patients need to be carefully followed up.

The Role of Echocardiography in the Management of Patients Undergoing a Ventricular Assist Device Implantation and/or Transplantation

Heart transplantation (HTx) is a curative treatment for patients with advanced heart failure (HF); however, since transplant opportunities are severely limited due to donor shortage, the left ventricular assist device (LVAD) has become a standard therapy for patients awaiting HTx. The role of echocardiography as a primary imaging modality to monitor the allograft function in transplant recipients as well as to optimize LVAD settings in LVAD recipients has been expanding. The purpose of this review is to highlight the clinical role of echocardiography in the management of patients under‐ going LVAD implantation and/or HTx. In particular, we overview (1) how to detect LVAD malfunction and device‐associated complication in LVAD recipients and (2) echocardiographic assessments of cardiac allograft rejection in transplant recipients.

Composite graft using the gastroepiploic artery, regarding the study design.

I read with great interest the paper on randomized study of composite grafting of the radial artery (RA) versus gastroepiploic artery (GEA) by Dr Santos [1]. I have several questions about this randomized study. As Dr Santos stated in the paper, the GEA is known to be a very fragile graft, prone to vasospasm. We recently published our series on GEA grafting [2], although we used the GEA as an in situ graft, our patency rate within 1 year after surgery was 97.1%, and the stenosis-free patency rate was 88.9%. The early stenosis rate of the GEA was 8.2%, which was much higher than the other grafts, and some of these stenoses were related to spasm. Dr Santos demonstrated that the early angiographic patency rate of GEA was 68.9%, and some of the graft occlusions were related to spasm. The number of occlusions was, for me, unacceptably high. Although the authors did not mention their saphenous vein patency rate, I assume their GEA patency rate may be significantly lower than that of the saphenous vein graft. The vasospasm of the GEA was already mentioned in another paper [3], and the use of the free GEA was not recommended due to the high frequency of vasospasm [4]. Another issue regarding this paper is that the percentages of the patients with diabetes were relatively low (20.0% in the GEA group and 26.7% in the RA group) and that the age of the study group was relatively young (56.0 in the GEA group and 55.7 in the RA group). From my point of view, these particular patients (non-diabetic and young patients) have optimal benefit from bilateral internal mammary artery (IMA) bypass grafting, since patients receiving bilateral IMAs have a lower risk of remote cardiac event rates [5]. I also could not understand why the study patients received composite grafts, which is a technically demanding procedure in a vasospastic conduit. Composite grafting is usually reserved for patients with severe atherosclerosis in the ascending aorta. In addition, nowadays, these patients undergo off-pump coronary artery bypass graftin (CABG), which can be performed without touching the aorta and minimizes the risk of postoperative stroke. However, Dr Santos performed all these cases under cardiopulmonary bypass, disregarding the advantage of composite grafting. I also cannot agree with the routine composite grafting of the GEA with the IMA, unless someone presented good graft patency with composite GEA grafting. Dr Santos stated that Ethical Research Committee agreed to this trial based on their preliminary data (patency rates of 96% of the RA and 88% of the GEA). However, they did not mention how many patients underwent angiography for the preliminary data, or how many of the patients received the composite grafts. I understood that all studied patients consented prior to the randomization, but I cannot agree to their study protocol: Why was the GEA used for composite grafting even though the preliminary data suggested a lower patency rate for the GEA than the RA? Why did the patients undergo on-pump bypass? Why did the patients not receive bilateral internal mammary artery grafting? Also, why did their internal review committee give permission for proceeding with this trial.