Jorge Balaguer

Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting and 1-Stop Hybrid Revascularization: Results From a Fully Integrated Hybrid Catheterization Laboratory/Operating Room

OBJECTIVESnThis study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room.nnnBACKGROUNDnThe value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved.nnnMETHODSnBetween April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings.nnnRESULTSnAmong the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients.nnnCONCLUSIONSnRoutine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline.

Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Infectious Diseases, Rush University, Chicago, Illinois; Department of Surgery, Saint Mary’s Hospital, Waterbury, Connecticut; Feinberg School of Medicine of Northwestern University, Northwestern Memorial Hospital, Chicago, Illinois; Cardiac Vascular and Thoracic Surgeons, Cincinnati, Ohio; Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; Department of Cardiovascular-Thoracic Surgery, Rush University Medical Center, Chicago, Illinois; and Division of Cardiac Surgery, The Ohio State University Medical Center, Columbus, Ohio

Safety of Minimally Invasive Mitral Valve Surgery Without Aortic Cross-Clamp

BACKGROUNDnWe developed a technique for open heart surgery through a small (5 cm) right-anterolateral thoracotomy without aortic cross-clamp.nnnMETHODSnOne hundred and ninety-five consecutive patients (103 male and 92 female), age 69 +/- 8 years, underwent surgery between January 2006 and July 2007. Mean preoperative New York Heart Association function class was 2.2 +/- 0.7. Thirty-five patients (18%) had an ejection fraction 0.35 or less. Cardiopulmonary bypass was instituted through femoral (176 of 195, 90%), axillary (18 of 195, 9%), or direct aortic (1 of 195, 0.5%) cannulation. Under cold fibrillatory arrest (mean temperature 28.2 degrees C) without aortic cross-clamp, mitral valve repair (72 of 195, 37%), mitral valve replacement (117 of 195, 60%), or other (6 of 195, 3%) procedures were performed. Concomitant procedures included maze (45 of 195, 23%), patent foramen ovale closure (42 of 195, 22%) and tricuspid valve repair (16 of 195, 8%), or replacement (4 of 195, 2%).nnnRESULTSnThirty-day mortality was 3% (6 of 195). Duration of fibrillatory arrest, cardiopulmonary bypass, and skin to skin surgery were 88 +/- 32, 118 +/- 52, and 280 +/- 78 minutes, respectively. Ten patients (5%) underwent reexploration for bleeding and 44% did not receive any blood transfusions. Six patients (3%) sustained a postoperative stroke, eight (4%) developed low cardiac output syndrome, and two (1%) developed renal failure requiring hemodialysis. Mean length of hospital stay was 7 +/- 4.8 days.nnnCONCLUSIONSnThis simplified technique of minimally invasive open heart surgery is safe and easily reproducible. Fibrillatory arrest without aortic cross-clamping, with coronary perfusion against an intact aortic valve, does not increase the risk of stroke or low cardiac output. It may be particularly useful in higher risk patients in whom sternotomy with aortic clamping is less desirable.

Intraoperative Grafts Assessment

Graft patency strongly influences early and late outcomes after coronary artery bypass grafting (CABG) surgery. The current standard of care in CABG surgery does not require intraoperative imaging. Because coronary angiography is rarely available in the operating room (OR), other techniques have been developed to assess graft integrity intraoperatively. The 2 most commonly used are the transit time flow measurement (TTFM) and the intraoperative fluorescence imaging (IFI). The TTFM is a quantitative volume flow technique, whereas the IFI is based on the fluorescent properties of indocyanine green. TTFM cannot define the degree of graft stenosis nor discriminate between the influence of the graft conduit and the coronary arteriolar bed on the mean graft flow. IFI provides a semiquantitative assessment of the graft patency with images that provide some details about the quality of coronary anastomoses. Both methods are valuable in identifying only at the extremes, that is, either patent or occluded grafts, and can confirm very good grafts; however, neither method is sensitive or specific enough in identifying more subtle abnormalities. These abnormal grafts most likely have poor long-term patency and are predestined to fail. The hybrid suite has the capability of serving both as a complete surgical OR and as a catheterization laboratory. It allows for routine completion angiogram following CABG surgery and identifies abnormal grafts, providing the opportunity to revise them with percutaneous coronary intervention or surgery before leaving the OR.

Tissue-based coronary surgery simulation: Medical student deliberate practice can achieve equivalency to senior surgery residents

OBJECTIVEnThe study objective was to assess the impact of dedicated instruction and deliberate practice on fourth-year medical students proficiency in performing a coronary anastomosis using a porcine heart model, compared with nonsimulator-trained senior general surgery residents.nnnMETHODSnTen fourth-year medical students were trained to perform a coronary anastomosis using the porcine simulator. Students trained for 4 months using deliberate practice methodology and one-on-one instruction. At the end of the training, each student was filmed performing a complete anastomosis. Eleven senior general surgery residents were filmed performing an anastomosis after a single tutorial. All films were graded by 3 independent cardiac surgeons in a blinded fashion. The primary outcome was the median final score (range, 1-10) of a modified Objective Structured Assessment of Technical Skill scale. The secondary outcome was time to completion in seconds. Statistical analysis used both parametric (Student t test) and nonparametric (Wilcoxon rank-sum) methods.nnnRESULTSnThe median combined final score for medical students was 3 (interquartile range, 2.3-4.8), compared with 4 (interquartile range, 3.3-5.3) for residents (Pxa0=xa0.102). The overall median individual final scores were 3 (interquartile range, 2-6) for grader 1, 3 (interquartile range, 2-5) for grader 2, and 4 (interquartile range, 3-5) for grader 3. For each individual grader, there was no difference in median final scores between medical students and residents. The mean time to completion was 792.7 seconds (95% confidence interval, 623.4-962) for medical students and 659 seconds (95% confidence interval, 599.1-719) for residents (Pxa0=xa0.118).nnnCONCLUSIONSnDedicated instruction of fourth-year medical students with deliberate and distributed practice of microvascular techniques using a porcine end-to-side coronary artery anastomosis simulation model results in performance comparable to that of senior general surgery residents. These results suggest that focused tissue simulator training can compress the learning curve to acquire technical proficiency in comparison with real-time training.

Detrimental effects of mechanical stretch on smooth muscle function in saphenous veins

OBJECTIVEnThis study evaluated the smooth muscle functional response and viability of human saphenous vein (HSV) grafts after harvest and explored the effect of mechanical stretch on contractile responses of porcine saphenous vein (PSV).nnnMETHODSnThe contractile responses (stress, 10(5) N/m(2)) of deidentified, remnant HSV grafts to depolarizing potassium chloride and the agonist norepinephrine were measured in a muscle organ bath. Cellular viability was evaluated using a methyl thiazole tetrazolium (MTT) assay. A PSV model was used to evaluate the effect of radial, longitudinal, and angular stretch on smooth muscle contractile responses.nnnRESULTSnContractile responses varied greatly in HSV harvested for autologous vascular and coronary bypass procedures (0.04198 ± 0.008128 × 10(5) N/m(2) to 0.1192 ± 0.02776 × 10(5) N/m(2)). Contractility of the HSV correlated with the cellular viability of the grafts. In the PSV model, manual radial distension of ≥ 300 mm Hg had no impact on the smooth muscle responses of PSV to potassium chloride. Longitudinal and angular stretch significantly decreased the contractile function of PSV by 33.16% and 15.26%, respectively (P < .03).nnnCONCLUSIONSnThere is considerable variability in HSV harvested for use as an autologous conduit. Longitudinal and angular stretching during surgical harvest impairs contractile responsiveness of the smooth muscle in saphenous vein. Avoiding stretch-induced injuries to the conduits during harvest and preparation for implantation may reduce adverse biologic responses in the graft (eg, intimal hyperplasia) and improve patency of autologous vein graft bypasses.

Comparative Effects of Angiotensin Receptor Blockade and ACE Inhibition on the Fibrinolytic and Inflammatory Responses to Cardiopulmonary Bypass

The effects of angiotensin‐converting enzyme (ACE) inhibition and angiotensin II type 1 receptor blockade (ARB) on fibrinolysis and inflammation after cardiopulmonary bypass (CPB) are uncertain. This study tested the hypothesis that ACE inhibition enhances fibrinolysis and inflammation to a greater extent than ARB in patients undergoing CPB. One week to 5 days before surgery, patients were randomized to ramipril 5 mg/day, candesartan 16 mg/day, or placebo. ACE inhibition increased intraoperative bradykinin and tissue‐type plasminogen activator (t‐PA) concentrations as compared to ARB. Both ACE inhibition and ARB decreased the need for plasma transfusion relative to placebo, but only ACE inhibition decreased the duration of hospital stay. Neither ACE inhibition nor ARB significantly affected concentrations of plasminogen activator inhibitor‐1 (PAI‐1), interleukin (IL)‐6, IL‐8, or IL‐10. ACE inhibition enhanced intraoperative fibrinolysis without increasing the likelihood of red‐cell transfusion. By contrast, neither ACE inhibition nor ARB affected the inflammatory response. ACE inhibitors and ARBs may be safely continued until the day of surgery.

Current status of hybrid coronary revascularization.

Hybrid coronary revascularization combines coronary artery bypass surgery with percutaneous coronary intervention techniques to treat coronary artery disease. The potential benefits of such a technique are to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery. Hybrid coronary revascularization has resulted in the establishment of new ‘hybrid operating suites’, which incorporate and integrate the capabilities of a cardiac surgery operating room with that of an interventional cardiology laboratory. Hybrid coronary revascularization has greatly augmented teamwork and cooperation between both fields and has demonstrated encouraging as well as good initial outcomes.

Contribution of Endogenous Bradykinin to Fibrinolysis, Inflammation, and Blood Product Transfusion Following Cardiac Surgery: A Randomized Clinical Trial

Bradykinin increases during cardiopulmonary bypass (CPB) and stimulates the release of nitric oxide, inflammatory cytokines, and tissue‐type plasminogen activator (t‐PA), acting through its B2 receptor. This study tested the hypothesis that endogenous bradykinin contributes to the fibrinolytic and inflammatory response to CPB and that bradykinin B2 receptor antagonism reduces fibrinolysis, inflammation, and subsequent transfusion requirements. Patients (N = 115) were prospectively randomized to placebo, ε‐aminocaproic acid (EACA), or HOE 140, a bradykinin B2 receptor antagonist. Bradykinin B2 receptor antagonism decreased intraoperative fibrinolytic capacity as much as EACA, but only EACA decreased D‐dimer formation and tended to decrease postoperative bleeding. Although EACA and HOE 140 decreased fibrinolysis and EACA attenuated blood loss, these treatments did not reduce the proportion of patients transfused. These data suggest that endogenous bradykinin contributes to t‐PA generation in patients undergoing CPB, but that additional effects on plasmin generation contribute to decreased D‐dimer concentrations during EACA treatment.

Prosthetic valve sparing aortic root replacement: an improved technique

We describe a modified surgical technique to treat patients with a previous history of isolated aortic valve replacement who now require aortic root replacement for an aneurysmal or dissected aorta. This technique consists of replacing the aortic root with a Dacron conduit, leaving intact the previously implanted prosthesis, and re-implanting the coronary arteries in the Dacron graft. Our technique differs from other techniques in that we do not leave behind any aortic tissue remnant and also in that we use a felt strip to obliterate any gap between the old sewing ring and the newly implanted graft. In our opinion, this promotes better hemostasis. We demonstrate that this technique is safe, feasible, and results in acceptable outcomes.