Emiliano Chiti

Combined Carotid and Cardiac Surgery: Improving the Results

BACKGROUND Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery. METHODS During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fishers exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test. RESULTS Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2). CONCLUSION In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.

The role of ivabradine in the incidence of perioperative coronary complications in patients undergoing vascular surgery.

The management of perioperative myocardial damage is focused on two issues: coronary plaque stabilization to reduce acute coronary syndromes and the subsequent supply ischemia (type 1MI) that occurs when a coronary plaque ruptures; and limiting surgical stress, which is the cause of the sustained myocardial oxygen supply–demand imbalance (type 2 MI) [1]. Prophylactic pre-operative coronary revascularization in patients scheduled for non-cardiac surgery has failed to show any benefit [2,3]. In contrast, the most recent guidelines recommended the use of β-blockers in patients having high-risk surgery [4]. On the other hand, results of some other clinical trials do not support the use of perioperative β-blockers for the high risk of bradycardia and hypotension, stroke and death [5,6]. Ivabradine, specific inhibitor of the If current in sinoatrial node myocytes, reduces heart rate independently of sympathetic activation, and has demonstrated a reduction in the risk of coronary events in patients with elevated heart rate (≥70 bpm) or angina at baseline [7,8]. The objective of the current study was to determine if ivabradine would be equally effective to β-blockers in reducing cardiovascular risk in patients undergoing major vascular surgery in whom beta-blockers were contraindicate or unsafe. 244 consecutive patients scheduled for open or endovascular aortic aneurysm repair. The internal review board approved the study project and all patients gave their informed consent. Patients with ≤2 cardiac risk factors on the Lee index score and a heart rate b 70 bpm were directly referred for surgery with optimal medical therapy, which must have been initiated at least 30 days before. Patients with ≥3 clinical risk factors on the Lee index score were referred for non-invasive cardiac stress testing echocardiography before surgery as recommended in the ESC guidelines [4]. All patients in the study received optimal medical therapy according to current guidelines [9] for at least 30 days before the planned surgical procedure and all patients with a heart rate ≥ 70 bpmwere assigned to a heart rate control strategy with βblockers or ivabradine. In the β-blocker group, bisoprolol 2.5 mgwas started once a day and titrated to achieve thepreferred restingheart rate range (60–65 bpm). In eligible patients, ivabradine was administered at a dose of 5–7.5 mg twice a day,with the sameheart rate target. The samedose ofβ-blockers or ivabradine was continued post-operative. At the discharge we confirm the treatment for six months and then to consult their cardiologist. The primary endpoint was a composite of all-cause mortality and nonfatal MI that occurred between screening and 30 days after the surgical procedure. Postoperative events were cardiac and overall complications. Troponin T levels were routinely recorded on postoperative days 1 and3orwhenever therewere symptomsor evidenceof new myocardial ischemia.

Duplex Scanning of the Ophthalmic Artery and Carotid Endarterectomy Response

To the Editor: Nuzzaci and colleagues presented in their article, “Duplex Scanning Exploration of the Ophthalmic Artery for the Detection of the Hemodynamically Significant ICA Stenosis,” data from 3 groups of patients (351 in total, with 548 internal carotid arteries [ICAs]) to support their argument that adding Doppler sonographic study of the ophthalmic artery (OA) to color duplex scanning of the extracranial ICA would improve the detection of critical ICA stenosis. I wish to make the following comments. First, the benefit of carotid endarterectomy in secondary stroke prevention has been proved among highly selected patients with high-grade ICA stenosis defined by angiography plus a stringent method of measurement.2 3 The benefit in primary stroke prevention is small but statistically significant in patients with high-grade ICA stenosis defined by angiography, although the ICA stenosis of many medically treated patients was defined by Doppler sonography of the extracranial ICA.4 Thus, results of the carotid endarterectomy trials2 3 4 may not apply when measurements of the ICA stenosis are made with other methods. It is imperative to compare the results of noninvasive studies with angiography at individual centers and to validate the noninvasive studies against angiography before results of noninvasive studies can be used to select the appropriate patients for carotid endarterectomy.3 In addition, results of carotid endartectomy trials2 3 4 are tied with the particular method of measuring the ICA stenosis on angiography, although 30%, 40%, 50%, 60%, 70%, 80%, and 90% stenosis in …