Carlo Cellini

Midterm clinical and angiographic results of radial artery grafts used for myocardial revascularization.

OBJECTIVE To evaluate the midterm angiographic results of the use of radial artery grafts for myocardial revascularization. METHODS The first 68 consecutive surviving patients who received a radial artery graft proximally anastomosed to the aorta at our institution were studied again at 5 years (mean 59 +/- 6.5 months) of follow-up; 48 of these patients had previously undergone an early angiographic examination. The response of the radial artery to the endovascular infusion of serotonin was evaluated 1 and 5 years after the operation, and the midterm status of the radial artery graft was correlated with the degree of preoperative stenosis of the target vessel and with calcium-channel blocker therapy. RESULTS The patency and perfect patency rates of the radial artery grafts 5 years after the operation were 91.9% and 87.0%, respectively. All radial artery grafts that were patent early after the operation remained patent at midterm follow-up, and early parietal irregularities in 7 patients were seen to have disappeared after 5 years. The early propensity toward graft spasm after serotonin challenge was markedly decreased at midterm follow-up. The continued use of calcium-channel antagonists after the first postoperative year did not influence the radial artery graft status, whereas the preoperative severity of the target-vessel stenosis markedly influenced the angiographic results. CONCLUSIONS The midterm angiographic results of radial artery grafts used for myocardial revascularization are excellent. The correct surgical indication is essential. Continued therapy with calcium-channel antagonists after the first year does not influence the midterm angiographic results.

Marked elevation of myocardial trace elements in idiopathic dilated cardiomyopathy compared with secondary cardiac dysfunction

OBJECTIVES We sought to investigate the possible pathogenetic role of myocardial trace elements (TE) in patients with various forms of cardiac failure. BACKGROUND Both myocardial TE accumulation and deficiency have been associated with the development of heart failure indistinguishable from an idiopathic dilated cardiomyopathy. METHODS Myocardial and muscular content of 32 TE has been assessed in biopsy samples of 13 patients (pts) with clinical, hemodynamic and histologic diagnosis of idiopathic dilated cardiomyopathy (IDCM), all without past or current exposure to TE. One muscular and one left ventricular (LV) endomyocardial specimen from each patient, drawn with metal contamination-free technique, were analyzed by neutron activation analysis and compared with 1) similar surgical samples from patients with valvular (12 pts) and ischemic (13 pts) heart disease comparable for age and degree of LV dysfunction; 2) papillary and skeletal muscle surgical biopsies from 10 pts with mitral stenosis and normal LV function, and 3) LV endomyocardial biopsies from four normal subjects. RESULTS A large increase (>10,000 times for mercury and antimony) of TE concentration has been observed in myocardial but not in muscular samples in all pts with IDCM. Patients with secondary cardiac dysfunction had mild increase (< or = 5 times) of myocardial TE and normal muscular TE. In particular, in pts with IDCM mean mercury concentration was 22,000 times (178,400 ng/g vs. 8 ng/g), antimony 12,000 times (19,260 ng/g vs. 1.5 ng/g), gold 11 times (26 ng/g vs. 2.3 ng/g), chromium 13 times (2,300 ng/g vs. 177 ng/g) and cobalt 4 times (86,5 ng/g vs. 20 ng/g) higher than in control subjects. CONCLUSIONS A large, significant increase of myocardial TE is present in IDCM but not in secondary cardiac dysfunction. The increased concentration of TE in pts with IDCM may adversely affect mitochondrial activity and myocardial metabolism and worsen cellular function.

Arterial Versus Venous Bypass Grafts in Patients With In-Stent Restenosis

Background—In patients who develop in-stent restenosis, successful revascularization can be difficult to achieve using percutaneous methods. This study was designed to verify the surgical results in this setting and to evaluate the potential beneficial role of arterial bypass conduits. Methods and Results—Sixty consecutive coronary artery bypass patients with previous in-stent restenosis and 60 control cases were randomly assigned to receive an arterial conduit (either right internal thoracic or radial artery; study group) or a great saphenous vein graft (control group) on the first obtuse marginal artery to complete the surgical revascularization procedure. At a mean follow-up of 52±11 months, patients were reassessed clinically and by angiography. Freedom from clinical and instrumental evidence of ischemia recurrence was found in 19 of 60 subjects in the study group versus 45 of 60 in the control series (P=0.01). The results of the arterial grafts were excellent in both the study and control groups (right internal thoracic artery patency rate, 19 of 20 for both, and radial artery patency rate, 20 of 20 versus 19 of 20; P=0.99). Saphenous vein grafts showed lower patency rate than arterial grafts in both series and had extremely high failure rate in the study group (patency rate, 10 of 20 in the study group versus 18 of 20 in the control group; P=0.001). Use of venous graft was an independent predictor of failure in the study group, whereas hypercholesterolemia was associated with graft failure in both series. Conclusions—Venous grafts have an high incidence of failure among cases who previously developed in-stent restenosis, whereas the use of arterial conduits can improve the angiographic and clinical results. Arterial grafts should probably be the first surgical choice in this patient population.

Individualized surgical strategy for the reduction of stroke risk in patients undergoing coronary artery bypass grafting.

BACKGROUND This study was designed to evaluate the efficacy of a protocol of systematic screening of the ascending aorta and internal carotid arteries and individualization of the surgical strategy to the ascending aorta and internal carotid arteries status in reducing the stroke incidence among patients undergoing coronary artery bypass grafting. METHODS On the basis of a pre- and intraoperative screening of the ascending aorta and internal carotid arteries, 2,326 consecutive patients undergoing coronary artery bypass grafting were divided in low, moderate, and high neurologic risk groups. In the high-risk group dedicated surgical techniques were always adopted and the reduction of the neurologic risk was considered more important than the achievement of total revascularization. RESULTS The incidence of perioperative stroke in the high-risk group was similar to those of the other two groups (1.1 versus 1.3 and 1.1%, respectively; p = not significant); however, angina recurrence was significantly more frequent in the high-risk group. CONCLUSIONS The described strategy allows a low rate of perioperative stroke in high-risk patients undergoing coronary artery bypass grafting. Whether the reduction of the neurologic risk outweighs the benefits of complete revascularization remains to be determined.

Should severe monolateral asymptomatic carotid artery stenosis be treated at the time of coronary artery bypass operation

OBJECTIVE The optimal treatment of severe monolateral asymptomatic carotid artery stenosis (SMACS) in patients undergoing coronary artery bypass grafting (CABG) is still controversial. MATERIALS AND METHODS This study is based on the in-hospital and mid-term (>5 years) clinical results of a cohort of 139 consecutive CABG patients with SMACS operated at our Institution between January 1989 and December 1995. In the first 73 patients (no carotid surgery group), the SMACS was left untouched at the time of coronary surgery, whereas in the remaining 66 (carotid endoarterectomy group), the carotid stenosis was treated either immediately before or concomitantly with the CABG procedure (depending on the severity of the anginal symptoms). RESULTS The overall preoperative characteristics of the patients were comparable. The in-hospital results were similar between the two groups with regard to mortality, stroke and major postoperative complications. However, at mid-term follow-up, significantly more patients of the no carotid surgery group suffered cerebral events (transient or permanent) ipsilateral to the SMACS or the lesion had to be operated on. CONCLUSIONS The concomitant treatment (either staged or simultaneous) of SMACS at the time of CABG does not influence the in-hospital results, but confers significant neurological protection during the years after the operation.

The Unclampable Ascending Aorta in Coronary Artery Bypass Patients A Surgical Challenge of Increasing Frequency

BackgroundThe unclampable ascending aorta (UAA) is a condition increasingly encountered during CABG procedures. We report our experience with CABG patients with UAA and place particular emphasis on the preoperative diagnosis and surgical management. Methods and ResultsUAA was diagnosed in 211 of 4812 consecutive CABG patients (4.3%). On the basis of the chest radiograph, echocardiogram, and coronary angiograph, a preoperative diagnosis was achieved in only 58 patients (27.4%). An age of >70 years, diabetes, smoking, unstable angina, diffuse coronaropathy, and peripheral vasculopathy were all predictors of UAA. Patients were treated with hypothermic ventricular fibrillation (no-touch technique n=129) or beating heart revascularization (no-pump technique n=82) depending on the possibility of founding an arterial cannulation site. The overall in-hospital mortality rate was 2.8% (6 of 211) with no differences between the 2 surgical strategies. The no-touch technique was associated with a greater incidence of neurological complications (stroke and transient ischemic attack), renal insufficiency, and stay in the intensive care unit and hospital. However, at midterm follow-up, more patients of the no-pump group had ischemia recurrence. ConclusionsA preoperative diagnosis of UAA is achievable only in a minority of patients, which highlights the necessity revising the current diagnostic protocols. The use of the no-touch technique is associated with an high perioperative risk but a superior possibility of complete revascularization, whereas adoption of the no-pump strategy ensures a smoother postoperative course at the expense of an higher incidence of ischemia recurrence.

A case of myocardial infarction effectively treated by emergency coronary stenting soon after a Bentall–De Bono aortic surgery

Postoperative ischemia may complicate cardiac surgery, despite myocardial protection and recent technical developments. Its medical management in the intensive cardiac care unit is usually efficient, although sometimes it requires the revision of the surgical site. In other cases, urgent coronary angiography and subsequent coronary stenting may resolve the situation. Ostial stenosis of coronary anastomoses is a well-known uncommon but dramatic complication after aortic surgery causing myocardial ischemia. Cases of effort angina have been described several months after surgery, but in some cases, acute myocardial infarction may occur days or weeks after intervention. We here describe an anteroseptal ST-elevation myocardial infarction soon after a Bentall aortic root replacement due to compression of the left main ostium by surgical glue, which has been effectively treated by emergency coronary stenting. This case highlights the importance of a joint management of acute myocardial ischemia after cardiac surgery by the cardiac surgeon and the interventional cardiologist.

Integrated approach for revascularization in multivessel coronary artery disease and porcelain aorta.

Abstract  We report two cases in which combined beating heart revascularization of the left anterior descending artery (LAD) and percutaneous angioplasty of the non‐LAD target arteries were adopted after the intraoperative detection of porcelain aorta and impossibility to complete surgical revascularization. This type of strategy preserves the benefits of surgical LAD grafting and complete revascularization and results in a simple and low‐risk technical procedure in an otherwise challenging setting.

Response to Letter Regarding Article, “Growth Properties of Cardiac Stem Cells Are a Novel Biomarker of Patients’ Outcome After Coronary Bypass Surgery”

We appreciate the interest of Drs Li and Shen in our study,1 which emphasizes the critical role that the insulin-like growth factor-1 (IGF-1) and IGF-1 receptor system has in defining the growth properties of human cardiac stem cells (hCSCs). We shared their view that IGF-1 positively interferes with the consequences of diabetes mellitus and dyslipidemia, and possibly with other cardiovascular pathologies. Based on our interest in IGF-1, a transgenic mouse model with cardiomyocyte-restricted overexpression of IGF-1 was developed.2 With this strategy, an increase in the number of ventricular myocytes was obtained, resulting in a significantly lower systolic and diastolic stress at the cellular level, together with an enhanced ability of the myocardium to sustain increases in pressure or volume loads. Overexpression of IGF-1 prevents the manifestation of the diabetic myopathy and is associated with a …

Long-term results of an open flexible prosthetic band for mitral insufficiency

Background use of a prosthetic ring is an integral part of any mitral valve repair and can influence the long-term stability of the results. We evaluated the long-term results of the AnnuloFlex ring implanted as an open flexible band in patients affected by degenerative mitral disease. Methods between 2001 and 2010, 82 patients (52 women, 30 men) with a mean age of 62 years, underwent repair of a prolapsing mitral valve with an AnnuloFlex band. One patient was reoperated on for a technical error and received a mechanical prosthesis, 3 were missing at follow-up, and the other 78 were prospectively followed up with clinical interviews and transthoracic echocardiography. Results the mean follow-up was 7.0 ± 1.8 years. Six patients died; 2 deaths were considered valve-related. The overall survival estimate at 10 years was 88.6% (95% confidence interval: 76.1%–94.8%). Freedom from endocarditis was 97.1% (95% confidence interval: 89.1%–98.5%). Freedom from thrombosis or hemorrhage was 93.7% (95% confidence interval: 81.6%–97.9%). Freedom from new or increased regurgitation was 93.1% (95% confidence interval: 87.3%–97.3%). The cumulative freedom from any valve-related event was 78.6% (95% confidence interval: 69.7%–97.1%). A single case of systolic anterior motion occurred before hospital discharge. Conclusion the long-term results of the AnnuloFlex band are excellent and stable.