Charles M. Geller

Radial artery conduits improve long-term survival after coronary artery bypass grafting.

BACKGROUND The second best conduit for coronary artery bypass graft surgery (CABG) is unclear. We sought to determine if the use of a second arterial conduit, the radial artery (RA), would improve long-term survival after CABG using the left internal thoracic artery (LITA) and saphenous vein (SV). METHODS We compared the 14-year outcomes in propensity-matched patients undergoing isolated, primary CABG using the LITA, RA, and SV versus CABG using the LITA and only SV. In all, 826 patients from each group had similar propensity-matched demographics and multiple variables. The primary endpoint was all-cause mortality obtained using the Social Security Death Index. RESULTS Perioperative outcomes including in hospital mortality (0.1% for the RA patients and 0.2% for the SV patients) were similar. Kaplan-Meier survival at 1, 5, and 10 years was 98.3%, 93.9%, and 83.1% for the RA group versus 97.2%, 88.7%, and 74.3% for the SV group (log rank, p = 0.0011). Cox proportional hazards models showed a lower all-cause mortality in the RA group (hazard ratio 0.72, confidence interval: 0.56 to 0.92, p = 0.0084). Ten-year survivals showed a 52% increased mortality for the SV patients (25.7%) versus the RA patients (16.9%; p = 0.0011). For symptomatic patients, RA patency was 80.7%, which was not different than the LITA patency rate of 86.4% but was superior to the SV patency rate of 46.7% (p < 0.001). CONCLUSIONS Using the LITA, SV, and a RA conduit for CABG results in significantly improved long-term survival compared with using the LITA and SV. The use of two arterial conduits offers a clear and lasting survival advantage, likely due to the improved patency of RA grafts. We conclude that RA conduits should be more widely utilized during CABG.

Arterial Grafts Protect the Native Coronary Vessels From Atherosclerotic Disease Progression

BACKGROUND We sought to examine the effect of different conduits on the progression of atherosclerosis in previously revascularized coronary territories. METHODS Between 1995 and 2010, 4,960 patients were discharged alive after primary isolated coronary artery bypass grafting (CABG) with a left internal thoracic artery (LITA) conduit and additional conduits as needed: radial artery (RA) or saphenous vein graft (SVG), or both. Seven hundred seventy-two patients had coronary angiography for recurrent symptoms an average of 5.5±3.5 years after CABG (range, 0.1-16 years). Cumulative graft patency and disease progression in the native vessels was estimated by the Kaplan-Meier survival method. The log-rank test was used to assess differences of disease progression per territory between different types of conduits. RESULTS Kaplan-Meier-estimated 1-, 5-, and 10-year overall disease progression in territories with patent LITAs was 0.01%, 4%, and 8%, respectively; with patent RA grafts, it was 0.01%, 6%, and 11%, respectively (log-rank test, p=0.157); and with patent SVGs it was 3%, 19%, and 43%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries in the anterior territory with patent LITA-to-left anterior descending (LAD) artery was 8%, and with patent RA grafts versus patent SVGs to the diagonal branches of LAD artery was 10% and 40%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries to the lateral territory with a patent RA graft was 11% versus 50% with a patent SVG (log-rank test; p<0.0001). CONCLUSIONS RA and LITA grafting has a strong protective effect against progression of native coronary artery disease in previously grafted vessels. Multiple arterial grafting may improve long-term survival by preventing progression of atherosclerosis in the native coronary vessels.

Time-Varying Survival Benefit of Radial Artery Versus Vein Grafting: A Multiinstitutional Analysis

BACKGROUND A survival benefit of radial artery use versus saphenous vein grafting in coronary artery bypass grafting (CABG) has been reported. We aimed to elucidate the relative radial artery survival benefit as a function of time after surgery from two independent CABG series. METHODS We compared 0- to 15-year survival with radial artery versus saphenous vein grafting in isolated, nonsalvage primary CABG with left internal thoracic artery to left anterior descending from two institutions: Ohio (radial artery [n=2,361; 61 years]; saphenous vein [n=2,547; 67 years]), and New York (radial artery [n=1,970; 58 years]; saphenous vein [n=2,974; 69 years]). Separate multivariate radial artery-use propensity models based on demographic, preoperative factors, intraoperative variables, and completeness of revascularization data were computed and used to derive propensity- and sex-matched CABG cohorts (1,799 [Ohio] and 995 [New York] pairs). A three-phase (early and late) mortality model was fit to Kaplan-Meier mortality estimates and used to derive relative radial artery versus saphenous vein hazard functions. RESULTS Radial artery use patterns and patient risk profiles differed substantially for New York and Ohio, with the New York radial artery cohort significantly younger and more male. Within-institution matched graft-type cohorts were well matched. Cumulative mortality was significantly better for radial artery at both institutions (p < 0.001 both). All mortality-time data were well described by the three-phase model, and the derived relative hazard functions were qualitatively and quantitatively similar for New York and Ohio, exhibiting maximal benefit between 0.5 and 5 years. CONCLUSIONS Despite substantial differences in radial artery use patterns during a 15-year period, our analysis in large propensity-matched radial artery and saphenous vein cohorts yielded remarkably similar, time-varying radial artery to saphenous vein survival benefit at both institutions. These converging findings based on two independent patient series extend currently available objective evidence in support of a radial artery survival advantage in CABG.

Left atrial dissection: etiology and treatment.

BACKGROUND Left atrial dissection (LatD) is a rare entity most commonly associated with mitral valve surgery. We have reviewed our experience with 4 patients to better define the etiology and the treatment of LatD. METHODS From 1991 to 2012, 4 patients experienced LatD after surgery (1 of 6,302, or 0.02%, of isolated coronary artery bypass grafting patients and 3 of 1,895, or 0.16%, of mitral valve patients). Patient and perioperative data and management were reviewed. RESULTS Two patients were women, and ages ranged from 49 to 80 years. Three patients underwent mitral procedures (two replacements with coronary artery bypass grafting and one repair) for mitral regurgitation. One patient underwent emergent isolated coronary artery bypass grafting after cardiopulmonary resuscitation for a left main dissection during percutaneous coronary intervention. Three LatDs were found during surgery, and one LatD was found 12 days after mitral repair and was successfully treated nonoperatively. The LatD was located along the posterior atrial wall originating from the atrioventricular junction in all cases and obstructed mitral valve inflow. Operative repair focused on the evacuation of hematoma, obliteration of the false lumen, and repair of the entry injury. No mortality occurred. CONCLUSIONS Left atrial dissection is a rare complication of cardiac surgery, probably related to a contained atrioventricular separation allowing pressurized blood to separate the layers of the posterior left atrium. Prompt intraoperative diagnosis, obliterating the false cavity, and addressing the entry point are essential. In contrast, a nonoperative approach in a stable patient with a delayed LatD suggests healing of the dissection, and atrial remodeling occurs.

Improving long term outcome for diabetic patients undergoing surgical revascularization by use of the radial artery conduit: a propensity matched study

BackgroundDiabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA.MethodsA propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010.ResultsWe compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/− SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122].ConclusionFor diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined.

Malignant B-Cell Lymphoma Arising in a Large, Left Atrial Myxoma

A case of large cardiac myxoma associated with primary B cell lymphoma is described in a patient presenting with acute obstructive left heart failure. Emergent surgical removal was performed along with mitral valve repair.

Optimal Conduit for Diabetic Patients: Propensity Analysis of Radial and Right Internal Thoracic Arteries

BACKGROUND Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revascularization of diabetic patients, we compared the outcomes for RA and RITA grafts to the circumflex coronary. METHODS From January 1, 1995, to December 31, 2011, 908 consecutive diabetic patients underwent first-time, isolated CABG (99% on-pump), 659 with the RA and 502 with the RITA, respectively, in two affiliated hospitals. Data were prospectively collected, and late mortality was determined from the Social Security Death Index. Propensity matching, based on preoperative and operative variables, identified 202 matched pairs from each group. RESULTS Long-term survival was similar for matched patients. Mortality, myocardial infarction, reoperation for bleeding, stroke, sepsis, and renal failure were not significantly different between groups. However, deep sternal wound infection (p<0.035) and respiratory failure (p<0.048) favored the RA group, in which the total major adverse events were significantly fewer (p=0.002). CONCLUSIONS In diabetic patients undergoing multivessel revascularization with either RA or RITA grafts to the circumflex coronary, long-term survival is similar. However, RA patients experienced significantly fewer respiratory or sternal wound adverse events. The RA is the preferred conduit to extend to more diabetic patients the recognized survival benefit of a multiple arterial graft strategy.

Left atrial dissection: an almost unknown entity

Left atrial dissection is an exceedingly rare but potentially fatal complication of cardiac surgery. It is most commonly associated with mitral valve surgery, including both replacement and repair, with a reported incidence rate of 0.16%. However, other cardiac surgical or catheter-based interventional procedures are also known as potential predisposing factors. The time of presentation from the cause of dissection varies extremely, ranging from immediate occurrence up to 20 years later. The dissection forms a large cavity between the endocardium and epicardium of the left atrium, causing obliteration of the left atrial cavity and resultant haemodynamic compromise, which almost always requires immediate surgical intervention. In contrast, left atrial dissection without haemodynamic instability can often be managed non-operatively with satisfactory outcomes. This article reviews this rare but relevant clinical entity to further elucidate the incidence, pathogenesis, clinical course, management and outcome of left atrial dissection.

Congenital coronary artery fistulae: a rare cause of heart failure in adults

Coronary artery fistulae are uncommon, reported in 0.25% of patients undergoing coronary angiography. Two patients with congenital coronary artery fistula and coronary artery disease who presented with symptoms of exacerbated congestive heart failure out of proportion to their atherosclerotic burden were successfully treated by epicardial fistula ligation and coronary artery bypass grafting with marked improvement in functional status.

Complicated Sporadic Cardiac Myxomas: A Second Recurrence and Myxomatous Cerebral Aneurysms in One Patient

A second recurrence of an excised nonfamilial cardiac myxoma is rare. Myxomatous cerebral aneurysms as a complication of cardiac myxomas are equally rare. A unique case of a patient with a total of 4 myxomas over a 20-year interval is presented. Her most recent presentation was a second recurrence of a left atrial myxoma, a de novo right atrial myxoma, and multiple cerebral myxomatous aneurysms. The challenging reconstruction of the normal anatomy was achieved with the use of porcine extracellular matrix patches. A diagnostic cerebral angiogram was later performed, and the aneurysms will be monitored for growth and possible intervention.