Keiji Matsubayashi

In Off-Pump Surgery, Skeletonized Gastroepiploic Artery is Superior to Saphenous Vein in Patients With Bilateral Internal Thoracic Arterial Grafts

BACKGROUNDnWhen the bilateral internal thoracic arteries are grafted to the left coronary arteries, it remains controversial whether the better conduit is provided by grafting the saphenous vein graft (SVG) or the gastroepiploic artery (GEA) to the right coronary artery territory. From the beginning of the present study, we consistently used the GEA in a skeletonized fashion using ultrasound scissors.nnnMETHODSnFrom January 2002 to December 2009, 320 consecutive patients with triple-vessel disease underwent in situ bilateral internal thoracic artery grafting to the left coronary arteries. Among the 320 patients, of whom 229 underwent GEA grafting to the right coronary artery and 91 SVG grafting, 85 propensity score-matched pairs were identified (C statistic, 0.68 [p < 0.001]).nnnRESULTSnThe mean follow-up duration was 5.1 ± 2.2 years. Seven-year freedom from death from all causes was 96.0% in the GEA group and 82.2% in the SVG group (p = 0.03); the rate of freedom from cardiac events (cardiac death, myocardial infarction, angina pectoris, repeat intervention, and heart failure) was 89.3% in the GEA group and 77.5% in the SVG group (p = 0.048). Multivariate Cox proportional hazard regression analysis showed that SVG use (without GEA) (p = 0.04; hazard ratio, 0.31; 95% confidence interval, 0.11 to 0.94) and smoking history (p = 0.02; hazard ratio, 0.22; 95% confidence interval, 0.07 to 0.81) were independent predictors of late cardiac event.nnnCONCLUSIONSnSkeletonized GEA grafting to the right coronary artery system is better than SVG grafting in patients with left-sided bilateral internal thoracic arterial grafts.

Off-Pump Bilateral Versus Single Skeletonized Internal Thoracic Artery Grafting in Patients With Diabetes

BACKGROUNDnWe compared the outcomes in propensity score-matched patients with diabetes undergoing off-pump coronary artery bypass grafting using skeletonized bilateral or single internal thoracic artery (ITA) and assessed any benefit of bilateral ITA grafting for outcomes.nnnMETHODSnAmong 770 consecutive patients undergoing isolated coronary artery bypass graft surgery (99.2% by off-pump technique without conversion to cardiopulmonary bypass), 423 patients had diabetes mellitus. After excluding patients who were older than 85 years of age (n = 10) or had only one target vessel at the left coronary area (n = 9), 170 pairs were matched using propensity scores created on the basis of 12 preoperative factors.nnnRESULTSnExcept for 1 patient, bilateral ITA was anastomosed to the left coronary system. Postoperative serum glucose was well controlled in both groups. The rate of deep sternal infection was similar between the groups. The mean observation period was 3.2 years. The 5-year survival free from overall death in bilateral versus single ITA grafting was 87.5% versus 70.8% (log-rank test p = 0.01). For freedom from cardiac death, the respective rate was 92.1% versus 78.7% (p = 0.01). For freedom from cardiac event, the respective rate was 91.0% versus 72.6% (p = 0.01). In multivariate Cox models, bilateral ITA grafting was significantly associated with a lower risk for overall death (hazard ratio, 0.45; 95% confidence interval, 0.22 to 0.89; p = 0.02), cardiac death (hazard ratio, 0.43; 95% confidence interval, 0.21 to 0.87; p = 0.02), and cardiac event (hazard ratio, 0.42; 95% confidence interval, 0.20 to 0.85; p = 0.02).nnnCONCLUSIONSnOff-pump skeletonized left-sided bilateral ITA grafting is associated with better mid-term outcomes than single ITA grafting, without increasing the risk of deep sternal infection.

Fenestrated Stent-Graft for Traumatic Juxtahepatic Inferior Vena Cava Injury

Purpose: To report the use of a fenestrated stent-graft to manage a traumatic rupture of the juxtahepatic inferior vena cava (IVC). Case Report: A 62-year-old man was involved in a traffic accident and hospitalized for severe right leg fractures. Computed tomography also uncovered liver contusion and retroperitoneal hematoma. The next day, he became hemodynamically unstable; a huge retroperitoneal hematoma had developed from a rupture of the juxtahepatic IVC. An emergent procedure to implant a self-expanding fenestrated stent-graft was successful in repairing the IVC injury and maintaining hepatic venous return. The patient recovered and continues in good health with a patent endograft 16 months after treatment. Conclusions: This experience supports the efficacy of fenestrated endograft implantation for emergent repair of IVC injuries, although proper facilities, an experienced interventional team, and an assortment of devices must be available.

Preoperative hemoglobin A1c predicts atrial fibrillation after off-pump coronary bypass surgery.

OBJECTIVEnDiabetes mellitus has been recognized as a risk factor for mortality and morbidity after coronary bypass grafting, but a significant association between diabetes mellitus and postoperative atrial fibrillation (AF) has not been found. Although a recent study demonstrated a potential link between preoperative hemoglobin A1c level and risk of postoperative AF, there has not been sufficient examination of this relationship. We aimed to investigate the association between preoperative hemoglobin A1c and AF after isolated off-pump coronary bypass grafting.nnnMETHODSnOf 912 consecutive patients undergoing isolated coronary bypass surgery, 805 were retrospectively analyzed for AF after excluding the following 107 cases: emergency (n=81), chronic AF (n=18), and pacemaker rhythm (n=8). We performed a group analysis with hemoglobin A1c levels categorized into tertiles of the baseline distribution and a continuous analysis based on 1% increments in hemoglobin A1c levels. The cutoff points for the tertiles were as follows: lower, 3.8-5.6% (n=283); middle, 5.7-6.7% (n=282); upper, 6.8-11.4% (n=240).nnnRESULTSnAF occurred in 159 patients (19.8%) after surgery. The median value (25th-75th percentile) of preoperative hemoglobin A1c was significantly lower in patients who developed AF than in those who did not (5.8 (5.4-6.3) vs 6.1 (5.5-7.2), p=0.01). The incidence of postoperative AF was 28.3% (80/283) in the lower tertile, 17.4% (49/282) in the middle tertile, and 12.5% (30/240) in the upper tertile (p for trend=0.01). The unadjusted odds ratio (95% confidence interval) for the association between hemoglobin A1c and postoperative AF was 0.70 (0.61-0.83) per 1% increase and 0.42 (0.29-0.70) for the upper versus the lower tertile. This association persisted after adjustment for the univariate predictors (0.74 (0.60-0.92) per 1% increase; 0.54 (0.31-0.90) for upper vs lower tertile) and the known risk factors (0.78 (0.63-0.95) per 1% increase; 0.55 (0.35-0.88) for upper vs lower tertile). The area under the receiver operator characteristic curve (95% confidence interval) for preoperative hemoglobin A1c as a predictor of postoperative AF was 0.70 (0.65-0.75) (p=0.01).nnnCONCLUSIONSnPreoperative hemoglobin A1c independently predicts the occurrence of AF after isolated off-pump coronary bypass grafting.

Safety and efficacy of central cannulation through ascending aorta for type A aortic dissection

The femoral and axillary arteries are common arterial cannulation sites for repair of type A dissection. However, these peripheral approaches involve certain problems. From January 2002 to August 2009, a total of 77 patients underwent emergency surgery for acute type A dissection. Central cannulation was applied in 26 patients and peripheral cannulation in 51. The arterial cannulation site was decided according to preoperative computed tomography findings, the patients condition, and intraoperative epiaortic ultrasonography findings. Central cannulation was avoided in cases of cardiac tamponade with shock. A cannula was inserted under ultrasound guidance using the Seldinger technique. Preoperative patient comorbidities and dissection-related complications were equally distributed between the two groups. Central cannulation was successfully performed in all 26 cases without incident. Operation time, cardiopulmonary bypass time, mean intubation time and mean intensive care unit stay duration were significant shorter in the central group. One patient (4%) died in the central group compared with four patients (8%) in the peripheral group (P=0.45). Direct central cannulation was successful for repair of type A dissection in selected patients and produced equal or superior surgical data to peripheral cannulation, thus providing one option in the approach to this condition.

Efficacy of Bilateral Internal Thoracic Artery Grafting in Patients With Chronic Kidney Disease

BACKGROUNDnThis study compared short-term and long-term outcomes in propensity score-matched patients with chronic kidney disease receiving bilateral internal thoracic artery (ITA) or single ITA grafting and assessed any benefit of bilateral ITA grafting for survival.nnnMETHODSnAmong 656 consecutive patients undergoing isolated coronary artery bypass grafting (99.1% by off-pump technique) between 2002 and 2008, 361 had chronic kidney disease with no history of dialysis. After excluding 10 patients who would not be potential candidates for bilateral ITA grafting because they were aged older than 85 years and 15 who had only one target vessel at the left coronary area, we identified 157 propensity score-matched pairs. Propensity scores were created based on 13 preoperative factors (C statistics, 0.787).nnnRESULTSnDuring a mean observation of 2.9 years, the rates of overall death and cardiac death (myocardial infarction, heart failure, and sudden death) in the bilateral ITA group were significantly lower than those in the single ITA group (5.1% vs 15.9%, p=0.01; 1.3% vs 8.3%, p=0.01). In multivariate Cox models including bilateral ITA grafting and all other potential predictors, bilateral ITA grafting was significantly associated with a lower risk for overall death (hazard ratio, 0.29; 95% confidence interval, 0.10 to 0.89; p=0.03) and cardiac death (hazard ratio, 0.14; 95% confidence interval, 0.03 to 0.63; p=0.02).nnnCONCLUSIONSnAmong patients with chronic kidney disease, bilateral ITA grafting provides better long-term survival than single ITA grafting.

Butterfly Resection Is Safe and Avoids Systolic Anterior Motion in Posterior Leaflet Prolapse Repair

BACKGROUNDnQuadrangular resection is a standard repair technique for prolapsing posterior leaflet; however, systolic anterior motion (SAM) sometimes occurs. Butterfly resection combines a triangular resection from the prolapsing edge and a reverse triangular resection to the annulus to remove redundancy, reduce leaflet height without annular plication, and minimize SAM. We assessed short-term and midterm outcomes and mitral leaflet configuration after repair vs quadrangular resection.nnnMETHODSnBetween 2002 and 2009, 53 patients underwent posterior leaflet resection with mitral annuloplasty, including quadrangular resection in 24 and butterfly resection in 29.nnnRESULTSnThe butterfly group had a significantly larger mean ring size (29.0 vs 27.8 mm, p = 0.04). SAM occurred in 2 patients in the quadrangular group and in none in the butterfly group. SAM completely resolved in 1 patient after inotropes were weaned, but the other needed a mitral valve replacement. Predischarge echocardiography showed the butterfly group had a significantly larger anterior leaflet/posterior leaflet ratio (3.05 vs 1.53, p < 0.01) and greater length from the coaptation point to the septum (2.91 vs 2.50 cm, p = 0.02) than the quadrangular group. Measurements at 3 months showed that the differences between the two groups persisted. During follow-up, no patients died or needed reoperation for recurrence. Moderate mitral regurgitation occurred in 1 in the quadrangular group.nnnCONCLUSIONSnButterfly resection can be safely performed without SAM and is durable in midterm follow-up. By echocardiography, this technique reduces the height of the posterior leaflet and shifts the coaptation point further away from the septum.

Preoperative C-reactive protein and atrial fibrillation after off-pump coronary bypass surgery

OBJECTIVEnThe purpose of the present study was to investigate the association between preoperative C-reactive protein (CRP) and atrial fibrillation (AF) after isolated off-pump coronary bypass surgery.nnnMETHODSnOf 683 consecutive patients undergoing isolated coronary bypass surgery by a single surgeon between January 2002 and March 2009, 552 were retrospectively analyzed after excluding the following 131 cases: on-pump surgery (n = 6), chronic AF (n = 14), pacemaker rhythm (n = 7), and preoperative CRP of ≥ 10 mg l(-1) (n = 104). We analyzed the correlation on a continuous basis per 1 SD increase in the logarithmically transformed value of CRP and on a group basis CRP level categorized into three groups: <1.0 mg l(-1), n = 196; 1.0-3.0 mg l(-1), n = 220; and 3.0-10.0 mg l(-1), n = 136.nnnRESULTSnAF occurred in 121 patients (21.9%, 121/552) of patients after surgery. The median value (interquartile range) of preoperative CRP (mg l(-1)) was significantly higher in patients who developed AF than in those who did not (2.2 (1.0-4.2) vs 1.3 (0.6-2.5), p = 0.001). The rate of 7-day survival free from AF was 65.4% in patients with CRP of 3.0-10.0 mg l(-1), 79.9% in those with CRP of 1.0-3.0 mg l(-1), and 85.7% in those with CRP of <1.0 mg l(-1) (log-rank test: p = 0.001). The unadjusted hazard ratio (95% confidence interval) for the association between CRP and postoperative AF was 1.65 (1.32-2.06) per 1 SD increase and 3.17 (1.86-5.40) for patients with CRP of 3.0-10.0 mg l(-1) versus those with levels of <1.0 mg l(-1). This association persisted after adjustment for the univariate predictors (1.43 (1.22-1.97) per 1 SD increase; 2.88 (1.67-4.97) for patients with CRP of 3.0-10.0 mg l(-1) vs <1.0 mg l(-1)) or the known risk factors (1.34 (1.18-1.86) per 1 SD increase; 2.52 (1.54-4.36) for patients with CRP of 3.0-10.0 mg l(-1) vs <1.0 mg l(-1)). The area under the receiver operating characteristic curve (95% confidence interval) for preoperative CRP as a predictor of postoperative AF was 0.68 (0.62-0.74) (p = 0.001).nnnCONCLUSIONSnPreoperative CRP is independently associated with the occurrence of AF after isolated off-pump coronary bypass surgery.

Giant Coronary Artery Aneurysm in the Left Main Coronary Artery: A Novel Surgical Procedure

Giant coronary artery aneurysm is quite rare and the corresponding surgical strategy is difficult to standardize. We present the case of a patient with giant coronary aneurysm involving the left main coronary artery who underwent an aneurysmectomy and coronary artery reconstruction with direct suture of the coronary vessels. Because of compression of the main pulmonary artery, the left main coronary artery was reconstructed using interposition of a short artificial graft.

Preoperative Heart Rate Variability Predicts Atrial Fibrillation After Coronary Bypass Grafting

BACKGROUNDnThe purpose of the present study was to investigate the association between preoperative heart rate variability and atrial fibrillation after off-pump coronary artery bypass graft surgery.nnnMETHODSnOf 524 consecutive patients undergoing isolated coronary artery bypass surgery, 390 were retrospectively analyzed after excluding the following 134 cases: on-pump surgery (n = 6), emergency (n = 106), chronic atrial fibrillation (n = 17), and pacemaker rhythm (n = 5). The following time-domain factors of heart rate variability were calculated: standard deviation of all normal-to-normal QRS (SDNN) and square root of mean of sum of squares of differences between adjacent normal-to-normal QRS (RMSSD).nnnRESULTSnAtrial fibrillation occurred in 98 patients (25%) after surgery. Patients not having atrial fibrillation had significantly lower heart rate variability than did patients having atrial fibrillation, with median values of 91 versus 121 for SDNN and 19 versus 25 for RMSSD. Reduced heart rate variability was significantly associated with a lower risk of postoperative atrial fibrillation: the adjusted hazard ratio (95% confidence interval) was 0.29 (0.17 to 0.49) for SDNN 99 ms or less and 0.47 (0.30 to 0.74) for RMSSD 20 ms or less. The area under the receiver operating characteristic curves for SDNN and RMSSD as a predictor of postoperative atrial fibrillation was 0.764 and 0.696, respectively.nnnCONCLUSIONSnReduced time-domain factors in preoperative 24-hour heart rate variability are independently associated with a lower risk of atrial fibrillation after off-pump coronary artery bypass surgery.