George Drossos

Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization : Propensity and risk modeling

OBJECTIVES We examined whether bilateral internal thoracic artery (BITA) revascularization is associated with any increased in-hospital mortality and complications compared with single internal thoracic artery (SITA) revascularization. BACKGROUND Despite proven long-term benefits, BITA revascularization has been slow to be adopted because of fear of increased early morbidity. METHODS We evaluated 1,697 consecutive patients undergoing BITA (n = 867) or SITA (n = 830) revascularization. We used propensity score analyses and adjusted risk models to address differences between arms. RESULTS There were 20 (2.3%) deaths in the BITA group versus 26 (3.1%) in the SITA group (odds ratio 0.73, p = 0.30). Propensity analysis identified several parameters that affected the decision to use BITA. Adjusting for propensity score and all potential risk factors, the odds ratio for death with BITA versus SITA was practically 1. Bilateral internal thoracic artery revascularization did not increase the number of in-hospital complications with the possible exception of deep sternal wound infections (11 [1.3%] vs. 3 [0.4%], p = 0.057). In multivariate modeling BITA increased the risk of deep sternal wound infections only in emergent cases and in older patients; the excess risk was negligible among 1,206 patients (71.1% of total) who did not have emergent revascularization and were < or =70 years old (risk difference 0.3%, p = 0.74). There was no difference in length of stay after adjustment for propensity factors (mean 11.3 vs. 11.7 days, p = 0.66). CONCLUSIONS Bilateral internal thoracic artery revascularization grafting confers no increased risk for early death and does not prolong hospital stay. The small increase in the risk of deep sternal wound infections does not affect the majority of patients.

Pericardial fat is strongly associated with atrial fibrillation after coronary artery bypass graft surgery

OBJECTIVES Recent evidence suggests that pericardial fat may represent an important risk factor for cardiovascular disease because of its unique properties and its proximity to cardiac structures. It has been reported that pericardial fat volume (PFV) is associated with atrial fibrillation (AF). The purpose of this study was to investigate the association between PFV and new-onset AF following coronary artery bypass graft surgery (CABG). METHODS PFV was measured using computed tomography in 83 patients with coronary artery disease scheduled to undergo elective isolated on-pump CABG. Patient characteristics, medical history and perioperative variables were prospectively collected. Any documented episode of new-onset postoperative AF until discharge was defined as the study end point. RESULTS Twenty-eight patients (33.7%) developed postoperatively AF during hospital stay. There was no significant difference in demographics and comorbidities among patients that maintained sinus rhythm (SR) and their AF counterparts. In univariate analysis, patients with postoperative AF had significantly more pericardial fat compared with SR patients (195 ± 80 ml vs 126 ± 47 ml, P = 0.0001). Larger left atrial diameter was also associated with postoperative AF (42.4 ± 6.9 mm vs 39.3 ± 4.8 mm, P = 0.017). Additionally, the prebypass use of calcium channel-blocking agents was independently associated with a lower incidence of postoperative AF, confirmed also by multivariate analysis (P = 0.035). In multivariate logistic regression analysis, PFV was the strongest independent variable associated with the development of postoperative AF (odds ratio: 1.018, 95% confidence interval: 1.009-1.027, P = 0.0001). The best discriminant value assessed by receiver operating characteristic analysis was 129.5 ml (sensitivity 86% and specificity 56%). CONCLUSIONS PFV is strongly associated with AF following CABG, independently of many traditional risk factors. Our findings suggest that PFV may represent a novel risk factor for postoperative AF. However, the role of pericardial fat in AF mechanism needs to be further delineated.

Harvesting Radial Artery and Neurologic Complications

Abstract  Background: Determination of the incidence, mechanisms, and diagnosis of hand complications after radial artery (RA) harvesting in coronary surgery (CABG). Methods: The study group (RA group) includes 54 patients who underwent RA harvesting in CABG operation. The control group (noRA group) consists of 131 patients who underwent CABG without the use of RA graft. The average follow‐up time was 16.36 ± 5.13 months. The patients were examined clinically, (a) for motor function abnormalities associated with radial and median nerve damage and (b) for sensory abnormalities, and the function of radial nerve was determined by eliciting the brachioradialis reflex. They answered in a formal scripted questionnaire to elicit symptoms and clinical points attributable to nerve damage during RA harvest, such as hand weakness, thumb weakness, sensation abnormalities on the back and on the palm side of the forearm, hand numbness, hand‐reversible paresis or forearm infection postoperatively, and any other upper limb abnormality.Results: Of the patients in the RA group, 34.09% reported left‐hand abnormality after operation. On the other hand, in the noRA group left‐hand abnormality was reported in 18.68% of patients. In the RA group sensation abnormality was reported in 34.09% of patients and thumb weakness alone was reported in 6.82% of patients. There was a statistically significant difference between the two groups. Low EuroSCORE was the predicting factor for motor abnormalities. Conclusions: More knowledge has been added about the neurologic complications after RA harvesting lately. We demonstrated the rate of motor and sensory abnormality, the potential mechanisms of these complications caused by surgical trauma or devascularization, and any predictive factors of complications. Optimal surgical techniques to avoid the damage of the responsible nerves are recommended.

Endovascular Stent-Graft Repair as a Late Secondary Procedure After Previous Aortic Grafts

Thoracic and abdominal aortic endovascular procedures as alternatives to aortic reoperations were studied in three different cases. An anastomotic aneurysm after previous thoracic aortic graft for coarctation, a second-stage elephant trunk repair (descending thoracic aortic aneurysm), and a secondary aneurysm proximal to a previous abdominal aortic graft were successfully treated with endovascular stent-grafts. During the follow-up period no lethal events or major aortic or graft-related complications were observed, except a type II endoleak in the anastomotic aortic aneurysm case. An endovascular stent-graft can be safely deployed into a previously implanted vascular graft, avoiding repeat surgery.

Endovascular repair of traumatic aortic transection

The present study reports a single center experience and mid-term results of endovascular repair of acute aortic traumatic transection on an emergency basis, instead of open surgical management. From January 2005 to December 2008, 13 cases of traumatic aortic transection with serious comorbidities, which underwent repair with thoracic stent grafts at our institution, were reviewed. The mean patient age was 32.5+/-7.8 years. During the follow-up period of 25.5+/-12.8 months, 12 patients were alive and one patient died of associated injuries. There were no intraoperative deaths, no incidence of paraplegia and no procedure-related mortality. The blood loses during the procedure were minimal. The thoracic aortic grafts were larger than the thoracic aorta by 12.4+/-5.7%. Five cases required complete or partial coverage of the left subclavian artery. There were two cases of graft collapse, which were successfully treated by endovascular reintervention. Our results suggest that this approach is safe, effective and can be performed with low rates of morbidity and mortality, especially in respect of patients with multiple injuries. Although initial results are encouraging, close long-term follow-up and technical improvements of the stent grafts are required.

Acute Type-A Dissection in a Patient with Severe Hemophilia A

EMOPHILIA A is a rare coagulation disorder characterized by low circulating levels of factor VIII of the coagulation cascade and an increased hazard of bleeding. Hemophilia A is classified as mild, moderate, or severe according to the circulating levels of factor VIII. In recent decades, considerable advances have been made in the management of hemophilia, and, as a result, the life expectancy of many hemophiliacs currently is estimated to be 60 to 70 years. 1 Thus, a broad new spectrum of pathologies is increasing in this population, such as acquired heart disease, some of which require specific and urgent management. Acute type-A aortic dissection is a life-threatening emergency condition associated with high mortality rates. Early complex surgical intervention is required, during which coagulopathy is often an important issue. The present report presents a case of a man with known severe hemophilia A who was treated urgently for acute type-A dissection. To the authors’ knowledge, this is the first report of a patient with hemophilia A and acute type-A dissection in the current literature. Challenging patient management issues are presented and therapeutic strategies are suggested for this rare combined clinical entity.

Operative stabilization of skeletal chest injuries secondary to cardiopulmonary resuscitation in a cardiac surgical patient.

Chest injury, including sternal and rib fractures, is the most common complication of cardiopulmonary resuscitation (CPR) that usually heals spontaneously. However, a small subset of patients has fractures that need mechanical treatment. We present a case of flail chest with sternum and left anterior rib fractures secondary to CPR in a cardiac surgical patient, which was mechanically ventilated due to respiratory complications. Open reduction and operative fixation with titanium osteosynthesis plates and locking screws in sternum and ribs was performed by a thoracic surgeon assisted by an orthopaedic surgeon. Anterior plating achieved chest stability and facilitated weaning from mechanical ventilation. The patient had an uneventful postoperative course, painfree, and experienced no sternal instability or infection throughout a six-month follow-up period. Sternal instability after cardiac surgery occurs infrequently but can be challenging to manage. Titanium plate fixation is an effective method to stabilize complicated flail chest, with clinical utility in a cardiothoracic practice.

Noninvasive Ventilation for Post-Pneumonectomy Severe Hypoxemia

ARDS remains a lethal complication after major lung resections. The reported mortality ranges from 50% to 100%, with increased incidence and mortality rates in pneumonectomy patients. The pathogenesis of early ARDS is still not fully understood, and the majority of patients will require mechanical ventilation. A review of the literature reveals that the role of noninvasive ventilation (NIV) in ARDS after lung resection is unclear, in contrast to its well established benefits in other types of respiratory failure. NIV is a technique of augmenting alveolar ventilation delivered by face mask, without introducing an endotracheal tube. NIV may reduce the need for endotracheal mechanical ventilation and improve clinical outcome in patients with acute respiratory failure after lung resection, avoiding complications related to intubation. We present a case of early ARDS following left-sided pneumonectomy, where bi-level positive airway pressure ventilation prompted a successful outcome.

Unligated Left Internal Mammary Artery Side Branch Resulting in Coronary Artery Steal Syndrome

Abstract  Whether internal mammary artery side branches have the potential for hemodynamically significant flow steal in cases of postcoronary surgery ischemia remains a controversial issue. We present a case in which coil embolization of two unligated side branches resulted in symptomatic improvement and resolution of ischemia as evidenced by myoview imaging. (J Card Surg 2011;26:487‐490)

Total circulatory arrest: a life-saving procedure for mediastinoscopic major hemorrhage

Acute hemorrhage during mediastinoscopy is a life-threatening complication. Although rare, iatrogenic damage of the thoracic great vessels is probable during mediastinoscopic biopsy. We report two cases of iatrogenic massive mediastinoscopic bleeding from the aortic arch and innominate artery managed initially by simple packing and controlled finally by cardiopulmonary bypass and repair under total circulatory arrest.