G. Färber

Cardiac surgery and phenprocoumon therapy— Is preoperative normalization of the international normalized ratio necessary?

Objectives:Patients on phenprocoumon presenting for surgery are often converted to heparin preoperatively. We assessed the impact of this conversion on outcome in cardiac surgery patients.Methods:From November 2007 to September 2013, 115 patients with phenprocoumon therapy presented for surgery and were operated either before or after the international normalized ratio (INR) had normalized (group A, INR > 1.3, n = 71; group B, INR ⩽ 1.3, n = 44 at day of surgery; group C, matched control cohort without preoperative phenprocoumon, INR ⩽ 1.3, n = 60).Results:Patients received a mix of cardiac surgical procedures (including valves, coronary artery bypass grafting, ventricular assist devices, and transplantation) without intergroup differences. Surgery was emergent in 11%, 2%, and 13% in groups A, B, and C, respectively (p = 0.2). Preoperative hospital stay was longest in group B (p < 0.01). Hospital mortality was high with 26% in group A (EuroSCORE 22 ± 22), 13% in group B (EuroSCORE 17 ± 16), and 7% in grou...

Coronary Artery Bypass Grafting using Bilateral Internal Thoracic Arteries through a Left-Sided Minithoracotomy: A Single-Center Starting Experience

OBJECTIVE  Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) is associated with the best long-term survival. However, using BITA increases the risk of sternal wound infections with conventional sternotomy. We describe here our initial results of minimally invasive CABG (MICS-CABG) using BITA. METHODS  Patients were operated through an incision similar to that of standard minimally invasive direct CABG. All operations were performed off-pump. We evaluated patients quality of life (QoL) using the Medical Outcomes trust, 36-Item Short Form Health Survey (SF-36). RESULTS  Between February 2016 and August 2017, we performed 21 cases of MICS-CABG using BITA. There was no intraoperative complication and no conversion to sternotomy or to on-pump. Two patients required reexploration through the same minithoracotomy for postoperative bleeding. Two cases of early postoperative graft failure were identified. There was no stroke or in-hospital mortality. The median duration of follow-up was 13 months, with a maximum of 19 months. Relief of angina was achieved in all patients. There was one readmission for superficial wound infection, which was conservatively treated. An 84-year-old man died 4 months after the operation. The remaining 20 patients attested good QoL with the SF-36 questionnaire. CONCLUSIONS  Myocardial revascularization using BITA can be safely achieved off-pump through a left-sided minithoracotomy with good postoperative and short-term outcomes.

Off-Pump Coronary Artery Bypass Grafting and Stroke—Exploratory Analysis of the GOPCABE Trial and Methodological Considerations

Background Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off‐pump CABG) may reduce severe adverse events including stroke. Methods In the German Off‐Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on‐pump) or without (off‐pump) cardiopulmonary bypass. This exploratory post‐hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke. Results There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off‐pump: 2.2%; on‐pump: 2.7%; odds ratio [OR]: 0.83 [0.5‐1.38]; p = 0.47). Within the off‐pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46‐1.60]; clampless device: 1.8%; OR 0.67 [0.26‐1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37‐2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on‐ and off‐pump CABG (off‐pump: 1.4%; on‐pump: 1.7%; OR 0.87 [0.64‐1.20]). Conclusion Within recent prospective randomized multicenter trials off‐pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off‐pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke.