D. Odavic

Despite modern off-pump coronary artery bypass grafting women fare worse than men

Female gender is an established risk factor for worse outcomes after cardiac surgery. Avoiding cardiopulmonary bypass (CPB) for coronary bypass grafting has an unknown effect on gender differences. Herein, we evaluate if gender has an impact on outcomes after modern off-pump coronary artery bypass grafting (OPCAB). From 2002 to 2007, we analyzed 983 patients (male: n=807/female: n=176) who underwent OPCAB with symptomatic multi-vessel disease at our institution. The link between gender and outcome was assessed by multivariate analysis and logistic regression. A composite endpoint was constructed from: 30-day-mortality, renal failure, prolonged intensive care unit (ICU) stay, neurological complications, use of intra-aortic balloon pump (IABP) and conversion to CPB. Mortality was 3.2% in women vs.1.8% in men (P=0.15) and the EuroSCORE was significantly correlated to gender (6.8 vs. 5.2; P<0.001), even after correction (P=0.036). Significant more occurrence of the composite endpoint was noted in women (39.8% vs. 29.0%; P=0.007) whereas for men the risk was much lower [odds ratio (OR) 0.65; 95% confidence interval (CI) 0.46-0.92; P=0.015]. For both genders the logistic regression revealed a risk increase of 15% per one-point-increase of EuroSCORE (corrected) (OR 1.15; 95% CI: 1.10-1.19; P<0.0001). Women had more frequently a prolonged stay at ICU (P=0.006) and had a higher stroke rate (2.3% vs. 1.2%; P=0.29). Complete revascularization was achieved similarly (95% vs. 94%; P=0.93). OPCAB offers low mortality and excellent clinical outcome. Women are more likely to experience postoperative complications. Even if partially neutralized by avoiding CPB, gender differences remain present with modern OPCAB strategies.

Avoidance of aortic side-clamping for proximal bypass anastomoses: better short-term outcome?

OBJECTIVES The benefit of off-pump coronary artery bypass (OPCAB) surgery may be reduced by strokes caused by microemboli produced after aortic side-clamping for proximal bypass anastomoses. The Heartstring device allows constructing proximal bypass anastomoses without side-clamping of the aorta. METHODS This retrospective study describes 260 consecutive patients who underwent OPCAB surgery; 442 proximal anastomoses were performed with the Heartstring device in this series. Ten percent of the patients were randomly sampled before discharge to undergo a coronary angiogram for assessment of graft patency. RESULTS Intraoperative Doppler measurements confirmed regular bypass function. Early mortality occurred in 4 patients (1.5%), and stroke occurred in 2 patients (0.8%). Device-related bleeding was negligible, and there were no cases of aortic dissection. Perioperative ischemia occurred in 8 patients (3.1%). Predischarge coronary angiography evaluations in 25 of the patients (of 260) showed that all 42 Heartstring-assisted anastomoses (of 442) were patent. CONCLUSIONS Clampless performance of proximal bypass anastomoses combined with OPCAB is associated with a very low incidence of stroke complications. Short-term follow-up has shown excellent results regarding bypass patency and other adverse events. Prospective randomized trials are required to confirm the advantage of this technique.

Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-to-Moderate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild‐to‐moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild‐to‐moderate TR underwent MV repair and concomitant TV repair with Tri‐Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color‐Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross‐clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)‐stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 &mgr;g/min, NA peak was 18 ± 11 &mgr;g/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in‐hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild‐to‐moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

New clip remover device to prepare saphenous vein graft for coronary bypass grafting

Objective: The accurate prepare of the saphenous vein (SV) is elementary to have good patency rates in myocardial revascularisation. To avoid intimal hyperplasia we use the eSVS Mesh (Kipps Bay Medical™, Minneapolis, USA). Caused by endoscopic harvesting technique of SV all side branches are clipped in situ. All Clips have to be removed and replaced by fine sutures (Prolene 6-0) in order to enable the covering the SV with the eSVS. How to remove the Clips without tearing the SV and its intima? Methods: We use a new designed clip remover in 40 patients. After harvesting the SV the distal end is intubated by a cannula with outlet. Into the SV a solution of sodium chloride 0.9% is applicated with a maximum pressure of 150 cm H2O. So the clips are exposed in a good position and they can be reopened and removed without sheer stress to the tissue by the clip remover device. Intraoperative graft patency was verified by MediStim. Result: All clips could be removed from vein. No tear that had to be repaired. Graft patency was 95% for eSVS treated with the new device. Histologic findings showed no intima lesions. Conclusion: This new tool is very feasible and save. Wrong placed clips on mammarian artery or veins are now easy and safely removable and a new can be applicated in correct position considering the potential intima lesion of the graft by clipping.