Dmitry Pevni

Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting.

ObjectiveTo evaluate the risk of deep sternal infection in a large patient cohort following bilateral internal thoracic artery (BITA) grafting using skeletonized BITA dissection. Summary Background DataComplete myocardial revascularization using BITAs improves long-term survival and lowers the rate of repeat operations. Harvesting of ITAs as skeletonized vessels preserves sternal collateral blood supply, thus enabling rapid sternal healing with less risk of deep sternal infection. MethodsOne thousand consecutive patients (763 men, 340 patients >70 years old, 304 diabetics) underwent skeletonized BITA grafting from April 1996 to July 1999. ResultsThe 30-day mortality rate was 3.4%. There were 10 perioperative infarcts, 16 strokes, and 22 deep sternal infections. There was an increased risk of deep sternal infection in repeat coronary artery bypass grafting (CABG) operations (15%), chronic obstructive pulmonary disease (COPD) (6.2%), congestive heart failure (4.7%), left ventricular dysfunction (ejection fraction < 35%, 4.5%), and longer aortic cross-clamping time. After adjustment for other demographic, clinical, and surgical predictors, the only independent predictors of deep sternal infection were repeat operations, COPD, and duration of aortic cross-clamping. No patients in the reoperation subgroup died, but three of six COPD patients with deep sternal infection died, and COPD was an independent predictor of overall (early + late) mortality. ConclusionsSkeletonized BITA grafting carries an acceptable risk of deep sternal infection but is not recommended for repeat CABG or for patients with COPD.

Arterial coronary artery bypass grafting is safe and effective in elderly patients

OBJECTIVESnBilateral internal thoracic artery grafting in elderly patients is controversial. We compared the outcome of bilateral internal thoracic artery grafting with that of single internal thoracic artery and saphenous vein and radial artery conduits in these patients.nnnMETHODSnPatients aged 70xa0years or more who underwent bilateral internal thoracic artery grafting between 1996 and 2008 (nxa0=xa01045) were compared with patients who underwent coronary artery bypass grafting with a single internal thoracic arteryxa0+xa0saphenous vein graft (nxa0=xa0582) or a single internal thoracic arteryxa0+xa0radial artery (nxa0=xa0249).nnnRESULTSnPrevalence of female gender, diabetes, emergency operation, and chronic obstructive pulmonary disease was lower in the bilateral internal thoracic artery grafting group compared with the internal thoracic arteryxa0+xa0radial artery and internal thoracic arteryxa0+xa0saphenous vein graft groups, whereas congestive heart failure and recent myocardial infarction were more prevalent in the bilateral internal thoracic artery grafting group. Operative mortality and sternal wound infections were not significantly different between groups. The mean follow-up was 8.17xa0±xa04.45xa0years. Ten-year survival (Kaplan-Meier) in the internal thoracic arteryxa0+xa0saphenous vein graft group was significantly lower than in the bilateral internal thoracic artery grafting and internal thoracic arteryxa0+xa0radial artery groups (Pxa0<xa0.001). Assignment to the saphenous vein graft group was also associated with decreased adjusted survival (Pxa0<xa0.001) compared with the bilateral internal thoracic artery and internal thoracic arteryxa0+xa0radial artery groups.nnnCONCLUSIONSnThis study supports the use of arterial grafts in elderly patients undergoing coronary artery bypass grafting.

New evidence for the role of TNF-α in liver ischaemic/reperfusion injury

Backgroundu2002 Tumour necrosis factor‐alpha (TNF‐α) plays a key role in causing ischaemia/reperfusion (I/R) injury. I/R also causes activation of xanthine oxidase and dehydrogenase (XDH + XO) system that, via generated free radicals, causes organ damage. We investigated the effect of ischaemia, reperfusion and non‐ischaemic prolonged perfusion (NIP) on TNF‐α and XDH + XO production in an isolated perfused rat liver model.

Surgical Myocardial Revascularization versus Percutaneous Coronary Intervention with Drug-Eluting Stents in Octogenarian Patients

OBJECTIVEnOur goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization.nnnMETHODSnWe retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006.nnnRESULTSnOf the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis.nnnCONCLUSIONnOctogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.

Ischaemia or reperfusion: which is a main trigger for changes in nitric oxide mRNA synthases expression?

Objectiveu2002 To investigate alterations in endothelial nitric oxide synthase and inducible nitric oxide synthase mRNA expressions and nitric oxide release in the myocardium during ischaemia/reperfusion and determine whether these changes are ischaemic and/or reperfusion dependent.

Protamine-induced Cardiotoxicity Is Prevented by Anti-TNF-α Antibodies and Heparin

Background We investigated the role of tumor necrosis factor &agr; (TNF-&agr;) in protamine-induced cardiotoxicity and the possibility of preventing or decreasing this effect by anti TNF-&agr; antibodies and heparin. Methods Isolated rat hearts were perfused for 60 min with Krebs-Henseleit solution (KH). The control group was perfused with KH alone, the KH > protamine > KH group was treated from the 20th to the 40th minute with protamine, and the KH + anti-TNF > protamine + anti-TNF > KH + anti-TNF group was treated the same as the KH > protamine > KH group but with anti-TNF-&agr; antibodies added throughout perfusion. The KH + heparin > protamine + heparin > KH + heparin group was treated the same as the KH > protamine > KH group but with heparin added to KH throughout perfusion. The KH > protamine > KH + heparin was perfused the same as the KH> protamine > KH group but with heparin added to KH for the last 20 min. Left ventricular (LV) function and coronary flow were measured every 10 min. TNF-&agr; was measured in the coronary sinus effluent. Left ventricular TNF messenger RNA was determined in the control and KH > protamine > KH groups at baseline and after the 40-min perfusion. Results Protamine caused a significant decrease of peak systolic pressure and dP/dt (to 25% of baseline). Significant amounts of TNF-&agr; in the effluent in the KH > protamine > KH group (102.3 ± 15.5 pg/min) and TNF messenger RNA expression in left ventricular samples were detected. TNF-&agr; was below detectable concentrations in the control, KH + anti-TNF > protamine + anti-TNF > KH + anti-TNF, and KH + heparin > protamine + heparin > KH + heparin groups. TNF-&agr; concentrations correlated with depression of LV peak systolic pressure (r = 0.984;P = 0.01) and first derivate of the increase of LV pressure (r = 0.976;P = 0.001). Heparin improved LV recovery and decreased protamine-induced TNF-&agr; release (KH > protamine > KH + heparin group). Conclusions Anti-TNF-&agr; antibodies and heparin prevent protamine-induced TNF-&agr; release and depression of LV function. Heparin improves protamine-induced depression of cardiac function.

Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients After Recent Myocardial Infarction

Background Bilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI. Methods and Results In total, 938 patients with recent MI (<3 months) who underwent BITA between 1996 and 2011 were compared with 682 who underwent SITA. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, peripheral vascular disease), to be female, and to have had a previous MI. Acute MI and 3‐vessel disease were more prevalent in the BITA group. Operative mortality of BITA patients was lower (3.0% versus 5.8%, P=0.01), and sternal infections and strokes were similar. Median follow‐up was 15.21 years (range: 0–21.25 years). Survival of BITA patients was better (70.3% versus 52.5%, P<0.001). Propensity score matching was used to account for differences in preoperative characteristics between groups. Overall, 551 matched pairs had similar preoperative characteristics. BITA was a predictor of better survival in the matched groups (hazard ratio: 0.679; P=0.002; Cox model). Adjusted survival of emergency BITA and SITA patients was similar (hazard ratio: 0.883; P=0.447); however, in the nonemergency group, BITA was a predictor of better survival (hazard ratio: 0.790; P=0.009; Cox model). Conclusions This study suggests that survival is better with BITA compared with SITA in nonemergency cases after recent MI, with proper patient selection.

Comparison of radial and bilateral internal thoracic artery grafting in patients with peripheral vascular disease

OBJECTIVESnThe composite T-graft with radial artery (RA) attached end-to-side to the left internal thoracic artery (ITA) provides arterial myocardial revascularization without the increased risk of deep sternal wound infection associated with harvesting 2 ITAs. However, many surgeons are reluctant to use RA in patients with peripheral vascular disease (PVD) due to concerns regarding the quality of the conduit in this subset of patients. The purpose of this study is to compare early- and long-term outcomes of arterial grafting with bilateral ITAs (BITA) to that of single ITA and RA in patients with PVD.nnnMETHODSnBetween 1999 and 2010, 619 consecutive patients with PVD (500 BITAs and 119 single ITA and RA) underwent myocardial revascularization in our institution.nnnRESULTSnOccurrence of following risk factors as female sex, age 70+, diabetes, unstable angina, emergency operation, cerebrovascular disease and chronic obstructive pulmonary disease was higher in the RA-ITA group. The RA-ITA group also had a higher logistic EuroSCORE (22.1 vs 13.3). Operative mortality and occurrence of deep sternal wound infection of the two groups was similar (4.2% vs 5.0% and 2.5% vs 4.0% for the radial and bilateral ITA, respectively). Median follow-up was 9.75 years. Unadjusted Kaplan-Meier 10-year survival of the two groups was similar (44.1% vs 49.6%, P u2009=u20090.7). After propensity score matching (100 pairs), assignment to BITA was not associated with better adjusted survival (hazard ratio 0.593, 95% confidence interval 0.265-1.327, P u2009=u20090.20, Cox model).nnnCONCLUSIONSnIn patients with PVD, complete arterial revascularization with left ITA and RA can be justified with regards to survival.