Harinder Singh Bedi

Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion

BACKGROUND In off-pump coronary bypass grafting (CABG), invasiveness is reduced but technically perfect anastomosis is jeopardized by cardiac motion and the need to hurry to reduce the time of ischemia. Also, a major cause of postoperative morbidity and mortality is ungrafted circumflex coronary artery disease. We have devised a means of overcoming these shortcomings and performing multivessel CABG. The objective of this study was to assess the safety and efficacy of our technique. METHODS One hundred patients with severe triple-vessel disease underwent multivessel off-pump CABG. For cardiac stabilization, a combination of local pericardial stabilization sutures and lifting and rotating the heart by means of posterior pericardial sutures were used. For myocardial perfusion, a technique of retrograde coronary sinus perfusion by arterial blood from the ascending aorta was used. RESULTS Each patient received an average of 3.8 grafts (range 3 to 5). Complications included conversion to cardiopulmonary bypass (CPB) in 1 patient and a perioperative myocardial infarction in the same patient. In all other patients we were able to perform a satisfactory grafting in all territories with no operative mortality. Rapid recovery allowed 95% of our patients to resume normal activity within 1 month. A predischarge graft angiogram in 35 patients showed 97.8% patency. CONCLUSIONS These results suggest that off-pump CABG with our techniques is effective and safe. Early clinical outcome and excellent patency rates suggest its more widespread use in selected cases.

Homograft aortic root replacement for destructive prosthetic endocarditis

Prosthetic aortic valve endocarditis with extensive destruction of the aortic root, annular abscess formation, and left ventriculoaortic discontinuity was seen in 3 patients, with aorta to left atrial fistula formation in 2. Homograft aortic root replacement with use of the anterior mitral leaflet of the aortic root to repair the fistula was used successfully in all 3 patients. Their case reports are discussed to highlight the use of the homograft aortic root in these complicated cases, and to report the occurrence of aorto-left atrial fistula in prosthetic valve endocarditis.

Can we perform coronary artery bypass grafting on the basis of computed tomographic angiography alone? A comparison with conventional coronary angiography

OBJECTIVES Multislice (64 slice) computed tomography (MSCT) angiography has recently emerged as a potential technique that can evaluate the coronaries in an accurate yet non-invasive manner. It has still not been shown whether the accuracy of the anatomy shown is precise enough to operate on the basis of MSCT alone. The aim of this prospective clinical trial is to compare MSCT to conventional coronary angiography (CCA), and to conclude whether MSCT alone is adequate for proceeding for CABG. METHODS 50 patients with proven severe coronary artery disease (CAD) on CCA for elective CABG underwent MSCT prior to CABG. The MSCT images were compared with CCA and the accuracy, sensitivity and specificity of detecting significant stenosis cross checked. Lesion-by-lesion analysis was made. CCA was used as the reference standard for location and degree of stenosis. RESULTS An excellent correlation was found between the CCA and MSCT findings. The overall sensitivity, specificity, positive (PPV) and negative (NPV) predictive values for quantitative assessment of stenosis >70% by MSCT compared to CCA were 98.5, 99.1, 82.3 and 99.8%, respectively. Comparing the maximal percent diameter luminal stenosis by MSCT versus CCA, the Pearsons correlation coefficient between the two modalities was 0.994 (p<0.0001). Bland-Altman analysis demonstrated a mean difference in percent stenosis of 0.05+/-2.42% (p=0.753). There was no significant correlation between stenosis difference and stenosis severity (Pearsons correlation coefficient=-0.027, p=0.695). 192 out of 207 (92.8%) of the observations were within +/-1.96 SD (4.8 to -4.7% stenosis difference). CONCLUSIONS The improved spatial and temporal resolution of the 64 row scanner provides an excellent correlation of MSCT with CCA. MSCT is a valuable tool in the armamentarium of the cardiac scientist. For the cardiac surgeon performing off pump CABG it helps in precise planning of the procedure and pre-judging the length of the conduit required. On the basis of our findings, in selected patients, we recommend the consideration of MSCT as a sole criteria for proceeding for CABG without CCA.

Papillary fibroelastoma of the mitral valve associated with rheumatic mitral stenosis.

Papillary fibroelastoma of the mitral valve diagnosed and treated in life is extremely rare. There have been eight cases documented so far. We report the first case of a mitral valve papillary fibroelastoma associated with severe rheumatic mitral stenosis and tricuspid regurgitation with stenosis. The tumor arose from the posteromedial papillary muscle of the mitral valve. The mitral valve was replaced after excising the valve with the tumor and the tricuspid valve was repaired. The patient did well and remains asymptomatic.

Morphometric analysis of the right gastroepiploic artery and the internal mammary artery

BACKGROUND The internal mammary artery (IMA) and the right gastroepiploic artery (RGEA) are frequently used as conduits for coronary artery bypass grafting. METHODS Morphometric measurements and histologic characteristics of the RGEA and the IMA were studied in 25 patients undergoing coronary artery bypass grafting. RESULTS External radius was found to be more in the IMA (range, 18 to 56 microns; mean, 39.56 microns) in comparison with the RGEA (range, 24 to 51 microns; mean, 32.52 microns; p < 0.01). There was no significant difference between the vessels in intimal thickness (IMA: 0.0 to 0.25 micron; mean, 0.05 micron; RGEA: 0.0 to 0.28 micron; mean, 0.09 micron), internal radius (IMA: 5 to 47 microns; mean, 28.40 microns; RGEA: 16 to 42 microns; mean, 23.56 microns), area of media (IMA: 1,690 to 3,476 microns2; mean, 2,777.52 microns2; RGEA: 1,659 to 3,600; mean, 3,012.44 microns2), intimal thickening index (IMA: 0.0 to 0.02; mean, 0.01; RGEA: 0.0 to 0.13; mean, 0.01), and medial index (IMA: 0.14 to 0.60; mean, 0.36; RGEA: 0.18 to 0.63; mean, 0.39). Histologic examination of the RGEA showed more defects in continuity of internal elastic lamina and rich smooth muscle cells in the media. CONCLUSIONS There was no difference in the morphometric measurements of the IMA and the RGEA except external radius, which was greater for the IMA. The histologic differences found in the RGEA may indicate an increased propensity for atherosclerosis of the RGEA as compared with the IMA. Some concern regarding the long-term patency of the RGEA in myocardial revascularization is warranted.

Geographical variations in the presentation of ruptured aneurysms of sinuses of valsalva: evaluation of surgical repair.

From 1981 to 1992, 13 male and 7 female patients underwent surgical correction for ruptured aneurysms of sinus of valsalva. A total surgical experience of 22 procedures including 2 reoperations is presented, accounting for 1.37% of open heart surgery for congenital heart disease at PGIMER Chandigarh. Ninty percent were in the 20‐to 40‐year age group. Forty‐five percent of patients had symptoms of > 1‐year duration (range 2 months to 20 years) and catastrophic onset of symptoms was noted in four (18%). All patients had localized aneurysms originating either in right coronary sinus (14 pts) or noncoronary sinus (8 pts). Sites of origin and rupture are detailed. Associated congenital abnormalities such as ventricular septal defect (VSD) (13 pts), aortic regurgitation (3 pts), and left superior vena cava and atrial septal defect (ASD) (1 pt each) were noted. The data pertaining to Oriental and Western groups of patients were analyzed, and the differences in age, mode of presentation, site of origin, rupture, and the spectrum of associated abnormalities were elucidated. The majority of the patients (86.4%) were operated by the Bicameral approach. Repair was tailored according to the extent and severity of the defect in the sinus of Valsalva and aortic valve annulus and also the presence and site of VSD.

Coronary-to-coronary bypass using a free internal mammary artery: an alternative.

Paucity of conduit of adequate length or quality poses a dilemma in the occasional patient. We report such a patient, in whom we used a modified anastomotic technique using the normal right coronary artery for the proximal anastomotic site of a free right internal mammary artery graft.

Bleeding risk of dietary supplements: A hidden nightmare for cardiac surgeons

We report a 55-year-old man who underwent off-pump bypass surgery and had diffuse oozing and bruising postoperatively. His hematological profile had been normal preoperatively and he had been off antiplatelets for a week prior to surgery. Postoperatively, a detailed talk revealed that he had been on dietary supplements containing fish oil and garlic – both of which are known to affect platelet function. It behooves the surgeon and anesthetist to screen all patients preoperatively for the possibility of intake of any dietary supplements taken by the patient.

Evaluation of Previously Cannulated Radial Arteries

To the Editor: I read with interest the article by Watson and colleagues1 on the evaluation of previously cannulated radial arteries. I have a number of queries. The paper fails to mention the time lapse between transradial artery coronary angiography and coronary artery bypass grafting (CABG). This is important, because the incidence of early radial artery (RA) occlusion after prior cannulation has been reported to be between 5% and 20%.2 Apart from occlusion, there can be damage to the arterial wall, endothelial disruption, damage to the tunica media, perivascular inflammation, and reactive hyperplasia with impaired vasodilatory capacity, which can occur within 3 months of transradial coronary angiography.3,4 The authors mention that “immediately after CABG, each patient had been given verapamil or diltiazem along with systemic heparinization.” Giving heparin after CABG is not a standard practice. What preparation of heparin was given (unfractionated or low-molecular-weight), in what dose, and for how long? The records inconsistently specified whether the right or left RA had been used for any particular graft. How then could the authors have known whether the RA under study had been cannulated? Hence their contention that they investigated patency in patients who had undergone transradial angiography is not totally true. Of the 3 occluded grafts, one was known to have been cannulated (and dissected) during coronary angiography. So why was this—a “known-to-have-been-dissected” radial artery—used? Of the 3 occluded grafts, the other 2 could also have been cannulated (or not). Either way, the percentage would be significantly affected. The authors also fail to mention whether the occluded grafts supplied native arteries that had critical stenosis. It has been documented that radial grafts to arteries with less than 80% stenosis are prone to blockage or will show a string sign.5 Kamiya and colleagues6 have shown that there is a substantially reduced patency rate for previously punctured RA grafts. We are strong proponents of the RA as a conduit but would advise against using a previously cannulated RA for at least 3 months. This time lapse is not absolute, and we always evaluate the RA by Doppler echocardiography (for size, calcification, and atherosclerosis), in addition, of course, to clinical evaluation with an Allen test.

Accuracy of dual-source computed tomography coronary angiography: evaluation with a standardised protocol for cardiac surgeons

Their comments allow us to report some additional information which was omitted due to space constraints. The mass was studied performing a 3-mm multidetector helical computed tomography (CT) scan, unfortunately without using a bolus tracking technique; an acquisition delay of 40 s, with a flow of 2.5 ml s 1 was applied. Themass appeared to be irregularly necrotic, and no significant arterial enhancement was evaluable (with the limits of the technique used). A critical revision of the acquired images was performed by an expert radiologist, and the hypothetic diagnosis of an encapsulated tumour such as a fibrous tumour or a leiomyosarcoma was addressed first. The possible theoretic utility in this clinical case of a magnetic resonance imaging (MRI), which was not performed, was posteriorly advocated according to the direct multiplanar imaging ofMRI, that, according to some authors [3], could help to delineate the diaphragm in certain anatomic areas that evade delineation on cross-sectional images, thus revealing its position in relation with the tumour. However, we completely agree with the colleagues that this examination is not a first-level tool in the diagnosis of intrathoracic masses, and its use should be reserved to selected cases, when diagnosis is not clear and further details could be important to achieve the correct diagnostic and therapeutic decision.