Federico Cammertoni

The Radial Artery: A Forgotten Conduit.

We reviewed the published literature on the clinical and angiographic outcome of radial artery (RA) grafts and on the comparison between the RA and the other conduits used in coronary operations. The RA is a better graft than the saphenous vein and comparable to the right internal thoracic artery (RITA); moreover, the RA seems a better choice than the RITA in patients at risk of sternal or pulmonary complications. We conclude that the RA should be preferred to the saphenous vein and considered at least equivalent to the RITA as the second conduit during every elective coronary artery bypass procedure.

Technical Issues in the Use of the Radial Artery as a Coronary Artery Bypass Conduit

The clinical and angiographic benefits related to the use of the radial artery (RA) as a bypass conduit have extensively been proven. However, due to its morpho-functional features and its anatomic position, successful use of the RA requires careful consideration of several technical issues. We herein summarize the current evidence on all the technical aspects related to the RA use in coronary surgery such as the preoperative evaluation of ulnar compensation, the different means of intraoperative vasodilatation, and the various harvesting techniques.

Surgical Treatment of Renal Cell Carcinoma With Cavoatrial Involvement: A Systematic Review of the Literature

The treatment of renal cell carcinoma (RCC) with cavoatrial involvement represents a major surgical challenge. To date, many surgical strategies have been proposed. However, general agreement on the best approach does not yet exist. Deep hypothermic circulatory arrest (DHCA) is the most commonly used method and allows complete tumor resection without increasing operative risk. Cardiopulmonary bypass (CPB) without circulatory arrest and methods using no CBP were also proposed, without a clear evidence of superiority of 1 technique over the others. Further studies are needed to evaluate the possible role of alternative techniques compared with deep hypothermic circulatory arrest.

Morpho-Functional Features of the Radial Artery: Implications for Use as a Coronary Bypass Conduit

Since its reintroduction in the early 1990s the radial artery has gained a major role in coronary surgery, currently representing a valid alternative to the right internal thoracic artery as a second arterial graft. However, its peculiar morphologic and functional features have both surgical and clinical critical implications that must be taken into account. In this review we summarize the current totality of evidence on the biologic characteristics of the radial artery, such as its histopathology, vasoreactivity, and remodeling, and discuss their potential implications for use as a coronary bypass conduit.

Long-Term Survival and Quality of Life of Patients Undergoing Emergency Coronary Artery Bypass Grafting for Postinfarction Cardiogenic Shock

BACKGROUND This study evaluated the long-term outcome of patients undergoing emergency coronary artery bypass grafting (eCABG) for cardiogenic shock after acute myocardial infarction. METHODS Sixty-seven consecutive patients underwent eCABG for cardiogenic shock at 2 European institutions during an 11-year period. Preoperative, intraoperative, postoperative, and long-term follow-up data of all patients were prospectively collected. RESULTS Hospital survival was 86% (58 of 67), with all deaths due to cardiac causes. At a mean follow-up of 78 ± 48 months (range, 1 to 153 months), 43 of the 58 patients (74%) discharged from the hospital were alive. Causes of death in 9 of the 15 follow-up deaths (60%) were noncardiac. Overall survival rate at the end of follow-up was 64% (43 of 67). Of the 43 survivors, 41 (95%) were in New York Heart Association Functional Classification I to II, ischemia free, had a Karnofsky performance status exceeding 80, and an excellent quality of life as assessed by the Seattle Angina Questionnaire. The use of cardiopulmonary bypass and the internal thoracic artery were associated with significantly better long-term survival. CONCLUSIONS The long-term survival and quality of life of patients who undergo eCABG for cardiogenic shock after acute myocardial infarction are good, and eCABG should be considered a valuable therapeutic option in this setting. The use of cardiopulmonary bypass and the internal thoracic artery at the time of the operation are strongly advocated.

Mini-aortic surgery with percutaneous cannulation and rapid-deployment valve.

Background We aimed to evaluate the results of the combined use of rapid-deployment valves, percutaneous cardioplegia delivery and left heart venting during minimally invasive aortic valve replacement surgery. Methods We identified 2 propensity-matched cohorts of patients who underwent primary elective isolated minimally invasive aortic valve surgery at our center over a 3-years period: 30 patients in group A had a conventional valve prosthesis and 30 patients in group B received a rapid-deployment valve using percutaneous cardioplegia delivery and percutaneous left heart venting. Skin incision length, intraoperative times, postoperative hospital outcomes, and 30-day echocardiographic results were compared between the 2 groups. Results Patients in group B had significantly shorter operative times and shorter skin incisions compared to group A (total operative time 196.0 ± 40.6 vs. 225.1 ± 30.8 min, respectively, p < 0.003; cardiopulmonary bypass time 79.9 ± 10.6 vs. 92.9 ± 17.2 min respectively, p < 0.001; crossclamp time 52.3 ± 9.6 vs. 74.9 ± 10.2 min, respectively, p < 0.001; incision length 3.6 ± 0.5 vs. 6.0 ± 0.6 cm, respectively, p < 0.001). Postoperative hospital outcomes and echocardiographic evaluation showed no significant differences. Conclusions The combined use of rapid-deployment valves, percutaneous cardioplegia, and left heart venting is safe and effective and allows a significant reduction of the skin incision together with a significant reduction of intraoperative times without affecting hospital outcomes or hemodynamic performance of the prosthetic valves.

Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study

OBJECTIVES Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting. METHODS The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients. RESULTS After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety. CONCLUSIONS In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.

Myocardial revascularization with both internal thoracic arteries 25 years after delayed repair for aortic coarctation

Aortic coarctation has been reported to cause alterations in the internal thoracic arteries that make these vessels unsuitable to be used as grafts for myocardial revascularization, especially if coarctation repair was performed in adulthood. This is the first reported bilateral internal thoracic grafting for myocardial revascularization in a patient who had undergone aortic coarctation repair 25 years earlier.

Acute heart failure related to a large left atrial myxoma

ABSTRACT An association between atrial myxoma and left ventricular failure is rarely described, is not completely understood, and may have multiple etiologies. We present a 49-year-old man with no history of cardiovascular disease who was admitted to our hospital with pulmonary edema. He was in atrial fibrillation with rapid ventricular response. Echocardiography showed a 10.5-cm left atrial myxoma, which had been asymptomatic until the onset of congestive heart failure in the presence of severe left ventricular systolic dysfunction. Left ventricular inflow obstruction associated with the giant atrial mass could not be the only cause for acute heart failure.

Rapid-deployment or transcatheter aortic valves in intermediate-risk patients?

Background Transcatheter aortic valve implantation and rapid-deployment aortic valve replacement represent two emerging therapies for patients with intermediate surgical risk and severe aortic stenosis. However, head-to-head comparisons between such novel therapies are lacking. Methods Severe aortic stenosis patients with intermediate surgical risk treated with rapid-deployment valve replacement at our institution were identified and compared with a propensity-matched population of patients who underwent transcatheter aortic valve replacement. Postoperative echocardiographic findings, in-hospital and midterm clinical outcomes were compared. Results We identified 60 patients who received transcatheter (n = 30) or rapid-deployment (n = 30) valve replacement. On postoperative echocardiography, freedom from paravalvular regurgitation was higher in the rapid-deployment valve group (p < 0.001), while postoperative mean transprosthetic gradient was lower in the transcatheter valve group (p = 0.03). Permanent pacemaker implantation was required more frequently in transcatheter valve patients (p = 0.01). Postoperative atrial fibrillation was more common in the rapid-deployment valve group (p = 0.03). Hospital mortality was similarly low in both groups (p = 0.33). At midterm follow-up, mortality was comparable (p = 0.42) but the rapid-deployment valve group still had a lower degree of paravalvular regurgitation. Conclusions Transcatheter and rapid-deployment valve replacement are promising treatment options for patients with intermediate surgical risk. These two techniques are associated with specific patterns of prosthesis function and postoperative complications. Further evaluation of the clinical impact of these therapies in this patient population is needed.