Jeremy R. Leonard

The radial artery: Results and technical considerations

The radial artery (RA) is a frequently used conduit for coronary artery bypass graft (CABG). We review the results of the use of the RA in CABG patients and discuss the unique technical considerations when using this conduit.

Incidence, risk factors, and prognostic impact of re-exploration for bleeding after cardiac surgery: A retrospective cohort study

BACKGROUNDnPostoperative re-exploration for bleeding (RB) is a frequent complication following cardiac surgery. We aim to assess incidence, risk factors, and prognostic significance of RB in a large cohort of cardiac patients.nnnMATERIALS AND METHODSnWe reviewed prospectively collected data for all patients who underwent cardiac surgery at our institution from 2007 to 2015. Logistic regression analysis was used to identify independent predictors of RB and specific outcomes. Propensity matching using a 1:1-ratio compared outcomes of patients who had RB with patients who did not.nnnRESULTSnDuring the study period, 7381 patients underwent cardiac operations. Of them, 189 (2.6%) underwent RB. RB was an independent predictor of in-hospital mortality (Odds Ratio (OR):2.62 Confidence Interval (CI):1.38-4.96; pxa0=xa00.003), major adverse events (OR:3.94, CI:2.79-5.62; pxa0<xa00.001), gastrointestinal events (OR:3.54 CI:1.73-7.24), renal failure (OR:2.44, CI:1.23-4.82), prolonged ventilation (OR:3.83, CI:2.60-5.62, pxa0<xa00.001), and sepsis (OR:2.50, CI:1.03-6.04, pxa0=xa00.043). Preoperative shock (OR:3.68, CI:1.66-8.13; pxa0=xa00.001), congestive heart failure (OR:1.70 CI:1.24-2.32; pxa0=xa00.001), and urgent and emergent status (OR:2.27, CI:1.65-3.12 and OR:3.57, CI:1.89-6.75; pxa0<xa00.001 for both) were predictors of RB operative mortality. Operative mortality, incidence of major adverse events, gastrointestinal events, and respiratory failure were all significantly higher in the propensity matched RB group (pxa0=xa00.050, pxa0<xa00.001, pxa0=xa00.046, and pxa0<xa00.001 respectively).nnnCONCLUSIONSnRB significantly increases in-hospital mortality and morbidity after cardiac surgery.

Open repair of descending and thoracoabdominal aortic aneurysms in octogenarians

OBJECTIVEnDespite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients.nnnMETHODSnOur institutional aortic database was queried to identify those ≥80xa0years old and thosexa0<80xa0years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes.nnnRESULTSnFrom 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80xa0years old. Octogenarians were more likely to be female (Pxa0= .018), with chronic pulmonary disease (Pxa0= .012), severe peripheral vascular disease (Pxa0< .001), and hypertension (Pxa0= .025). Degenerative aneurysms were more common among octogenarians (Pxa0< .001), whereas chronic and acute dissections were more common among those younger than 80xa0years (Pxa0< .001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80xa0years, 5.7%; ≥80xa0years, 5.6%; Pxa0= .852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80xa0years, 6.7%; ≥ 80xa0years, 1.0%; Pxa0= .029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80xa0years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; Pxa0< .001), which led to significantly shorter cross-clamp times in this cohort (26.6xa0minutes vs 30.7xa0minutes; Pxa0< .004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; Pxa0< .025). Short- and long-term survival was significantly reduced in octogenarians.nnnCONCLUSIONSnIn select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome.

Totally endoscopic coronary artery bypass surgery: A meta-analysis of the current evidence

BACKGROUNDnTotally endoscopic coronary artery bypass (TECAB) has emerged as an alternative to other minimally invasive techniques. However, limited TECAB results are available to date. The purpose of this systematic review is to examine the existing literature to give an objective estimate of the outcomes of TECAB using a meta-analytical approach.nnnMETHODSnA comprehensive online review was performed in Ovid MEDLINE®, Ovid EMBASE and The Cochrane Library from 2000 to July 2017. Eligible studies included single arm TECAB studies as well as comparative studies (TECAB vs minimally invasive direct coronary artery bypass (MIDCAB)). Pooled event rates and odds ratios (ORs) for operative mortality, perioperative myocardial infarction (MI), perioperative stroke, graft patency and repeat revascularization were estimated. Single arm and pairwise comparisons were performed.nnnRESULTSnSeventeen single arm TECAB articles (3721 patients, weighted mean follow-up 3.3years) were included. The pooled event rate was 0.80% (95%CI: 0.60-1.2%) for operative mortality, 2.28% (95%CI: 1.7-3%) for perioperative MI, 1.50% (95%CI: 1.1-2.0%) for perioperative stroke, 2.99% (95%CI: 1.6-5.4%) for repeat revascularization and 94.8% (95%CI: 89.3-97.5%) for early graft patency (weighted mean follow-up 10.1months). On pairwise meta-analysis 376 patients (263 TECAB and 113 MIDCAB) were included. No difference in operative mortality (OR=0.25, 95%CI: 0.02-2.83), perioperative MI (OR=3.09, 95%CI: 0.37-26.12) or perioperative stroke (OR=1.33, 95%CI: 0.17-10.26) was found between the two techniques.nnnCONCLUSIONSnTECAB has an acceptably low operative risk and a good early patency rate. The incidence of perioperative MI requires further investigation. The dearth of data comparing TECAB to open approaches compels the need for future comparative trials.

Nonbacterial Thrombotic Endocarditis Presenting with Leg Pain and a Left Atrial Mass Lesion

Systemic lupus erythematosus (SLE) is a major cause of nonbacterial thrombotic endocarditis (NBTE) associated with intracardiac sterile vegetations. It is rare for vegetations to present as an atrial tumor. This report describes a 48-year-old female with SLE and antiphospholipid syndrome complicated by recurrent thrombosis on anticoagulation. A large left atrial mass lesion was detected on echocardiography during a work-up for leg burning. Infective endocarditis could not be confirmed, and hence left atrial mass lesion was the most likely diagnosis. The patient was managed surgically and the pathology report revealed fibrin networks in a pattern similar to that of thrombosis, characteristic of NBTE.

Surgery for Acute Presentation of Thoracoabdominal Aortic Disease

Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.

Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms

Objective Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. Methods We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long‐term outcomes. Results From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41‐5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53‐9.10). Women also had significantly lower 5‐year survival. Conclusions Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period. Graphical Abstract Figure. No Caption available.

Dual antiplatelet therapy post CABG?—perhaps, but… why not a radial artery instead?

In a recent issue of the Journal of the American Medical Association , Zhao and colleagues report their results from a recently completed randomized trial assessing the efficacy of dual antiplatelet therapy (DAPT) in patients undergoing coronary artery bypass graft (CABG) surgery (1).

Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?

PurposeOver the past three decades, there have been a plethora of retrospective observational data and meta-analyses which support the hypothesis of improved clinical outcomes using bilateral internal thoracic arteries (BITA) when compared to saphenous vein grafts (SVGs). However, recently published results have brought this thinking into doubt. We discuss the existing literature on the subject and attempt to clarify the appropriate use of BITA in coronary artery bypass surgery (CABG).MethodsA review of all existing meta-analyses on BITA was conducted to better understand the utility of BITA in CABG. A review of the largest randomized controlled trials on the subject was then compared to the observational data.ResultsIn all existing meta-analyses, BITA shows a significant advantage over the use of a single internal thoracic artery (SITA) with SVGs. The two largest randomized controlled trials evaluating BITA failed to show a survival advantage and brought into question the complications associated with BITA.ConclusionsAt present, the use of multiple arterial grafts remains a reasonable choice, particularly in young patients, provided that their use does not increase the operative risk. Further evidence currently being collected may lend a definitive answer in the near future.

Surgery for chronic type B dissection with aneurysmal degeneration

PurposeOpen repair of descending thoracic or thoracoabdominal aortic aneurysm (TAAA) continues to carry a not insignificant operative risk, even in experienced hands. Over the past three decades, there has been considerable improvement in both the mortality and morbidity associated with these procedures. Herein, we describe our operative results and long-term outcomes in patients with chronic type B aortic dissections.MethodsReview of the aortic surgical database was conducted to identify all consecutive patients who underwent repair of TAAA for chronic type B dissection from May 1997 to March 2018. The primary end point was operative mortality with secondary end points as the composite of major adverse events as well as each of the individual complications.ResultsOne hundred and fifty-three patients met inclusion criteria with 54.9% (84/153) having surgery on an elective basis. The mean age was 58.9xa0years with a majority of male gender—107/153 (69.9%). Eighty-three (54.2%) of the TAAA were extent I, while 36 (23.5%) were extent II and 34 (22.3%) extent III-IV. Operative mortality was 8.5% (13/153) with eight of the deaths in patients who presented with extent II TAAA. On Kaplan-Meier survival analysis, 87.5% (95% confidence interval (CI) 77.9–97.1%) of the elective cohort were alive after 5xa0years while only 69.9% (CI 55.2–84.6%) of those in need of urgent/emergency intervention survived (pu2009=u2009.039).ConclusionsIn a majority of patients with chronic type B dissections, reproducibly, excellent outcomes can be achieved with relatively low risk of mortality. In the higher risk subsets of patients with extent II TAAA, careful consideration and discussion of expected outcomes will help inform the decision-making process.