Fadi Basile

Bispectral index as an indicator of cerebral hypoperfusion during off-pump coronary artery bypass grafting.

Bradycardia and hypotension are common during off-pump coronary artery bypass grafting (OPCAB). We present a case of possible reversible global cerebral hypoperfusion during distal grafting of the left circumflex coronary artery. The bispectral index (BIS) suddenly decreased from values of 45-50 to 0 during distal grafting. Neurologic evaluation after immediate tracheal extubation in the operating room was normal and the 58 yr old patient did not suffer any neurologic sequelae. Postoperative recovery was uneventful and the patient was discharged 5 days after surgery. Cerebral hypoperfusion is a possible complication during OPCAB. BIS monitoring in OPCAB could be an indicator of cerebral hypoperfusion.

Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epidural-based anesthesia.

PurposeTo examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).MethodsOne hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 μg·kg−1, propofol 1 to 2 mg·kg−1 and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL·hr−1 and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by iv fentanyl boluses (up to 15 μg·kg−1) and remifentanil 0.1 to 0.2 μg·kg−1·min−1, followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.ResultsNinety-five patients were extubated within 25 min after surgery (PCA,n = 33; TEA,n = 62). Five patients were not extubated immediately because their core temperature was lower than 35°C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05).ConclusionImmediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.RésuméObjectifVérifier la faisabilité de l’extubation immédiatement après un pontage aortocoronarien à cœur battant (PACCB) en utilisant une analgésie avec opioïdes ou une analgésie péridurale thoracique (APT), et comparer l’analgésie postopératoire avec APT continue ou analgésie auto-contrôlée (AAC).MéthodeCent patients consécutifs devant subir un PACCB ont été inclus dans un audit prospectif. Après l’induction de l’anesthésie avec 2 à 5 μg·kg−1 de fentanyl, 1 à 2 mg·kg−1 de propofol et l’intubation endotrachéale facilitée par du rocuronium, l’anesthésie a été maintenue avec du sévoflurane ajusté selon le monitorage de l’index bispectral. L’analgésie périopératoire a été fournie par l’APT (n = 63) dans l’espace intervertébral T3/T4 ou T4/T5 avec de la bupivacaïne à 0,125 % à raison de 8 à 14 mL·h−1 et de bolus répétés de bupivacaïne à 0,25 % pendant l’opération. Chez les patients traités aux anticoagulants ou qui refusaient l’APT, l’analgésie périopératoire a été réalisée par des bolus iv de fentanyl (jusqu’à 15 μg·kg−1) et de 0,1 à 0,2 μg·kg−1 ·min−1 de rémifentanil, suivi de morphine en AAC postopératoire (n = 37). La température corporelle a été maintenue dans une salle d’opération chauffée et par des couvertures chauffantes à air forcé.RésultatsOn a pu extuber 95 patients pendant les 25 premières minutes postopératoires (AAC, n = 33; APT, n = 62). Cinq patients n’ont pu être extubés immédiatement, étant donné leur température centrale plus basse que 35 °C. Deux patients ont été ré-intubés : l’un, du groupe d’APT, pour agitation, l’autre, du groupe d’AAC, à cause de douleurs intenses et de dépression respiratoire induite par la morphine. Les scores de douleur postopératoires ont été faibles, ceux du groupe d’APT étant significativement plus bas immédiatement après, puis à 6, 24 et 48 h postopératoire (P < 0,05).ConclusionL’extubation immédiate est possible après le PACCB en utilisant soit une analgésie avec opioïdes, soit une APT. L’APT, comparée à l’AAC avec morphine, produit des scores de douleurs postopératoires significativement plus bas.

Upper Extremity Vein Graft for Aortocoronary Bypass

Twenty-four autologous vein grafts taken from the upper extremities were used in 13 patients undergoing aortocoronary bypass procedures. All of these patients had had previous bilateral saphenous vein stripping. Clinical follow-up between 3 months and 6 1/2 years is reported. Ten patients were recatheterized. There was neither operative mortality nor appreciable morbidity. All the patients are alive and well at the present time. Eleven out of 13 were in New York Heart Association (NYHA) Class I 3 months after operation. Nine patent grafts out of 10 were seen during recatheterization in 6 patients studied less than 9 months after operation. In a subgroup of 5 patients followed for more than 1 year, 2 are now in NYHA Functional Class I, 2 in Class II, and 1 in Class III. Graft patency had been determined in 4 of these patients. Five grafts out of 8 were patent, 2 of them with gross abnormalities. In conclusion, we have some reservations about the long-term fate of these grafts.

Awake cardiac surgery using a novel anesthetic technique.

Objectif Decrire les premiers cas publies de cardiochirurgie vigile au Canada. De plus, presenter une nouvelle technique anesthesique qui est une combinaison de bloc femoral et ďanesthesie peridurale thoracique haute.

Comparison between technetium-99m-teboroxime and thallium-201 dipyridamole planar myocardial perfusion imaging in detection of coronary artery disease

Technetium-99m (TC-99m)-teboroxime is a new myocardial perfusion imaging agent. The purpose of this prospective study was to compare Tc-99m-teboroxime with thallium-201 imaging after the administration of dipyridamole. Thirty patients referred for the evaluation of chest pain were studied with both thallium-201 and Tc-99m-teboroxime dipyridamole scans (mean interval 2 days). Dipyridamole was administered at 0.142 mg/kg/min for 4 minutes. Planar imaging (3 standard views) was obtained at 5 and 240 minutes after the injection of 2.2 mCi of thallium-201. Tc-99m-teboroxime (18 to 25 mCi) was injected after dipyridamole infusion. A second injection, at rest, was repeated 4 hours later. Planar imaging (3 standard views of 1 minute/view for the first 2 views, and 90 seconds for the last view) was obtained 2 minutes after Tc-99m-teboroxime injection. Blinded reading was performed by 3 observers. Thallium-201 showed perfusion defects in 182 myocardial segments corresponding to 33 of 45 (73%) significantly stenosed coronary arteries (greater than or equal to 70% reduction in endoluminal diameter), and Tc-99m-teboroxime detected 160 abnormal segments corresponding to 29 of 45 (64%) stenosed arteries. Thallium-201 and Tc-99m-teboroxime studies were normal in 3 patients. In conclusion, this study shows that there is a good correlation in the imaging results found with thallium-201 and Tc-99m-teboroxime using dipyridamole infusion on both a segmental and a diagnostic comparison.

Catheter-Assisted Totally Thoracoscopic Coronary Artery Bypass Grafting: A Feasibility Study

BACKGROUND The purpose of this study is to examine the feasibility of performing totally thoracoscopic internal mammary-to-coronary artery bypass grafting with the assistance of radiologically guided catheter intervention. METHODS Fourteen dogs were subjected to mobilization of the internal mammary artery and anastomosis of it to the left anterior descending coronary artery over an angiographic catheter inserted into the internal mammary artery under fluoroscopy. The anastomosis was completed over the catheter using sutures and the application of fibrin glue. Eight animals underwent the anastomosis after their sacrifice. The other 6 animals were put on closed chest cardiopulmonary bypass and had their anastomosis done after intraaortic balloon occlusion and cardioplegic arrest of the heart. All animals had an angiographic and pathologic examination at the completion of the anastomosis. RESULTS Anastomosis was completed in all dogs. Three anastomoses leaked and two were noted to be stenosed at completion of the anastomosis. One leak was sealed by application of fibrin glue. Both stenotic anastomoses were caused by suturing of the back wall when a short angiographic catheter could not be positioned across the anastomosis. CONCLUSIONS Minimally invasive totally thoracoscopic mammary-to-coronary artery bypass grafting with catheter assistance is feasible. Technical improvement and appropriate instrumentation are required to minimize anastomotic failure.

Heart Valve Replacement with the Björk-Shiley Monostrut Valve: Early Results of a Multicenter Clinical Investigation

To evaluate the clinical performance of the Björk-Shiley Monostrut prosthesis, five centers combined their early experience. Between May, 1982, and June, 1985, 537 prostheses were implanted in 486 patients at these centers: 246 patients had aortic valve replacement (AVR), 163 underwent mitral valve replacement (MVR), and 47 had double-valve replacement (DVR). Thirty patients underwent other, more complex procedures. Concomitant cardiac procedures were performed in altogether 25%. Overall hospital (30 days) mortality was 5.1% (3.6% for AVR, 4.3% for MVR, 8.3% for DVR, and 16.6% for other procedures). The patients were followed up at 6- to 9-month intervals from 6 to 48 months (mean follow-up, 33 months). Follow-up was 99.6% complete. Late mortality was 7.2%. The three-year survival rate was 91.0% for AVR, 92.3% for MVR, and 76.2% for DVR. There was no structural failure of the prosthesis. No instances of valve thrombosis and fatal thromboembolism occurred in anticoagulated patients. The three-year incidence of freedom from thromboembolic events (including TIA) was 89.8% for AVR, 94.9% for MVR, and 90.2% for DVR. Preoperative and postoperative data for the assessment of mechanical hemolysis was available in 60% of the patients. The degree of mechanical hemolysis was low and did not change with time. Although the follow-up is still short, the Björk-Shiley Monostrut prosthesis appears to represent an improvement over previous Björk-Shiley models, particularly with regard to durability.

A novel composite coronary bypass graft strategy: the saphenous vein bridge—a pilot study

OBJECTIVES The aim of this pilot study was to describe and assess the safety of a novel composite graft technique for coronary artery bypass grafting (CABG) surgery. A saphenous vein is grafted to the left anterior descending artery (LAD) and other anterolateral coronary arteries, creating a saphenous vein bridge (SVB) and the left internal mammary artery (LIMA) is anastomosed to the SVB, distributing the blood flow distally (LIMA-SVB). METHODS All patients who underwent CABG with the LIMA-SVB between 2005 and 2008 at our centre were enrolled in this study. Perioperative data were retrospectively collected from hospital charts, and the clinical follow-up was completed by telephone interview. Graft patency was assessed by computed tomography angiography (CTA) in patients with the longest follow-up time (n = 20). RESULTS A total of 256 patients (mean age: 67 ± 12 years; 79% male) received 4.0 ± 1.0 grafts, including 2.2 ± 0.4 distal grafts provided by the LIMA-SVB. Nine (3.5%) deaths and 4 (1.6%) myocardial infarctions (MIs) were noted in the perioperative period. With a median follow-up time of 36 months [inter-quartile range 31-44], 1 (0.5%) MI and 2 (1.0%) strokes were reported. At 51 months post-surgery [47-53], CTA demonstrated a LIMA pedicle (n = 20) and SVB (n = 42) patency rate of 100 and 93%, respectively. Specifically, the LIMA-SVB patency rate was 100% to the LAD and 85% to diagonal arteries. Aortocoronary vein grafts (n = 38) patency rate in the same patients was 87%. CONCLUSIONS Revascularization of the anterolateral territory using the LIMA-SVB is a promising approach considering its clinical safety and favourable patency rate results. A prospective randomized clinical trial is underway to compare this technique to conventional CABG.

Une nouvelle technique anesthésique pour la chirurgie cardiaque vigile

Objectif Decrire les premiers cas publies de cardiochirurgie vigile au Canada. De plus, presenter une nouvelle technique anesthesique qui est une combinaison de bloc femoral et ďanesthesie peridurale thoracique haute.

Composite versus conventional coronary artery bypass grafting strategy for the anterolateral territory: study protocol for a randomized controlled trial

BackgroundIn severe coronary artery disease, coronary artery bypass grafting (CABG) surgery is indicated to re-establish an adequate blood supply to the ischemic myocardium. Effectiveness of CABG surgery for symptom relief and mortality decrease should therefore depend on bypass graft patency. As bypass using a left internal mammary artery (LIMA)-to-left anterior descending coronary artery (LAD) anastomosis allows the best results in terms of graft patency, we designed a new surgical technique using a saphenous vein graft as a venous bridge to distribute the LIMA flow to the cardiac anterolateral territory. This novel strategy could extend the patency benefits associated to the LIMA. Other potential benefits of this technique include easier surgical technique, possibility to use saphenous vein grafts as vein patch angioplasty, shorter saphenous vein grafts requirement and reduced or eliminated manipulations of the ascendant aorta (and associated stroke risk).Methods/DesignBetween July 2012 and 2016, 200 patients undergoing a primary isolated CABG surgery using cardiopulmonary bypass with a LAD bypass graft and at least another target on the anterolateral territory will be randomized (1:1) according to 1) the new composite strategy and 2) the conventional strategy with a LIMA-to-LAD anastomosis and revascularization of the other anterolateral target(s) with a separated aorto-coronary saphenous vein graft. The primary objective of the trial is to assess whether the composite strategy allows non-inferior anterolateral graft patency index (proportion of non-occluded CABGs out of the total number of CABGs) compared to the conventional technique. The primary outcome is the anterolateral graft patency index, evaluated at one year by 256-slice computed tomography angiography. Ten years of clinical follow-up is planned to assess clinical outcomes including death, myocardial infarction and need for revascularization.DiscussionThis non-inferiority trial has the potential to advance the adult cardiac surgery field, given the potential benefits associated with the composite grafting strategy.Trial registrationClinicalTrials.gov: NCT01585285.