Marek Cisowski

Randomized Comparison of Stentless Versus Stented Valves for Aortic Stenosis Effects on Left Ventricular Mass

Background— Aortic valve replacement (AVR) is the established treatment for severe aortic stenosis. In response to the long-term results of aortic homografts, stentless porcine valves were introduced as an alternative low-resistance valve. We conducted a randomized trial comparing a stentless with a stented porcine valve in adults with severe aortic stenosis. Methods and Results— The primary outcome was change in left ventricular mass index (LVMI) measured by transthoracic echocardiography and, in a subset, by cardiovascular MR. Measurements were taken before valve replacement and at 6 and 12 months. Patients undergoing AVR with an aortic annulus ≤25 mm in diameter were randomly allocated to a stentless (n=93) or a stented supra-annular (n=97) valve. There were no significant differences in mean LVMI between the stentless versus stented groups at baseline (176±62 and 182±63 g/m2, respectively) or at 6 months (142±49 and 131±45 g/m2, respectively), although within-group changes from baseline to 6 months were highly significant. Changes in LVMI measured by cardiovascular MR (n=38) were consistent with the echo findings. There was a greater reduction in peak aortic velocity (P<0.001) and a greater increase in indexed effective orifice area (P<0.001) in the stentless group than in the stented group. There were no differences in clinical outcomes between the 2 valve groups. Conclusions— Despite significant differences in indexed effective orifice area and peak flow velocity in favor of the stentless valve, there were similar reductions in left ventricular mass at 6 months with both stented and stentless valves, which persisted at 12 months.

Primary stenting versus MIDCAB: preliminary report–Comparision of two methods of revascularization in single left anterior descending coronary artery stenosis

BACKGROUND Percutaneous revascularization is a well-accepted method of treatment for a single left anterior descending coronary artery (LAD) stenosis. With the introduction of primary stenting, it has become the treatment of choice for a LAD lesion. In the last few years however, the introduction of minimally invasive cardiac surgery, video-assisted left internal thoracic artery (LITA) harvesting, and robotic surgery have raised the question as to whether minimally invasive surgical revascularization would be competitive with percutaneous coronary interventions in cases of single-vessel stenoses. METHODS A group of 100 patients with Canadian Cardiovascular Society class II to IV, and angiographically confirmed single critical stenosis of the LAD (type A or B), were treated with direct primary stenting (group 1, n = 50), or with endoscopic atraumatic coronary artery bypass grafting (group 2, n =50). RESULTS All patients in a group 1, obtained a very good angiographic and clinical effect. No acute postoperative complications were noted at 1 month of follow-up. However, at 1 month of follow-up, 3 patients (6%) developed restenosis of the LAD, and at 6 months follow-up, 6 patients (12%), developed restenosis of the LAD. In these cases, repeated percutaneous coronary interventions of the target vessel were successfully performed. In group 2, very good operative results were observed. In 1 and 6 months of follow-up, all patients remained asymptomatic. Critical stenosis of the left internal thoracic artery-LAD anastomosis was angiographically documented in 1 case (2%). This patient was successfully treated with balloon angioplasty. CONCLUSIONS The study results document the superiority of endoscopic atraumatic coronary artery bypass grafting over direct primary stenting in LAD revascularization, along with the slightly higher costs of the surgical procedure.

Integrated minimally invasive direct coronary artery bypass grafting and angioplasty for coronary artery revascularization

OBJECTIVE Minimally invasive direct coronary artery bypass (MIDCAB) through the anterolateral minithoracotomy has become a promising therapeutic option in patients with lesion in left anterior descending artery (LAD), especially in multimorbid, elderly and reoperated patients with type C or B lesions. To expand the benefits of MIDCAB concept to patients with multivessel disease, a hybrid myocardial revascularization procedure (HMR) combining surgery of the LAD with interventional procedures for additional coronary lesions has recently been introduced. METHODS Between January 1999 and September 2001, 50 patients (37 male, 13 female, mean age 54.8+/-20.1 years) underwent an HMR procedure. MIDCAB with endoscopic left internal thoracic artery (LITA) harvesting, followed by percutaneous coronary intervention (PCI) for additional coronary lesions and percutaneous transluminal coronary angioplasty (PTCA), was performed in 11 patients (22%) and stenting in 39 patients (78%). Angiographic assessment of graft patency was performed in all patients during the PCI procedure. The clinical follow-up period was 3-32 months. RESULTS There were no early and late deaths. Baseline Canadian Cardiology Society (CCS) class was 2.8+/-0.7 versus 1.1+/-0.9 (P<0.001) 30 days after HMR procedure. There were no major acute in-hospital cardiac events. Angiographic studies showed patent LIMA-LAD graft in 50 patients (100%). We showed good quality of anastomosis in 49 patients (98%). There was a moderate graft stenosis in one patient (2%). At long term follow-up, the rate of major cardiac events was 12%. Five patients (10%) developed restenosis after PCI, and one patient (2%) developed significant stenosis in site of LITA-LAD anastomosis; redo PCI was performed successfully. CONCLUSIONS The hybrid procedure is a safe and effective method for complete revascularization in selected patients with double-vessel coronary artery disease (patients with type B or C lesions in the proximal LAD). This method allows performance of complete revascularization with minimization of surgical trauma. So far, long-term results of HMR are limited by the results of PCI.

Coronary endarterectomy in left anterior descending artery combined with coronary artery bypass grafting – midterm mortality and morbidity

Introduction Completeness of myocardial revascularization is essential in surgical treatment of coronary artery disease. The aim of this study is to determine the effectiveness of coronary endarterectomy as an adjunct to coronary artery bypass grafting (CABG) in the most difficult cases. Material and methods Among 1559 patients who had CABG in our department, the cases of 17 who underwent an adjunct left anterior descending endarterectomy were analyzed. All procedures were performed with median sternotomy, extracorporeal circulation and in mild hypothermia (34°C), by the same surgeon. No coronary artery endarterectomy was planned before surgery. Results There was no infarction or cardiac arrest during hospitalization. Only one patient required mechanical circulatory support (intra-aortic balloon counterpulsation). Each patient was contacted and investigation for major adverse cardiac and cerebrovascular events (MACCE) was performed. Eleven patients (65%) already underwent midterm clinical evaluation. There was no death, myocardial infarction or cerebrovascular incident during the entire period (mean follow-up at 15.3 months). One patient required urgent coronarography due to chest pain. No other patient had chest pain or significant deterioration of ventricular function in echocardiography. Conclusions Outcomes and potential indications for performing left anterior descending coronary endarterectomy as an adjunct to CABG are discussed.

The Likert scale is a powerful tool for quality of life assessment among patients after minimally invasive coronary surgery

Introduction Health-related quality of life (QoL) is an acknowledged index of treatment effectiveness. There are several methods of its evaluation which are predisposed to different risk of bias. Aim To investigate the agreement between objective and subjective tools of QoL assessment in patients who underwent endoscopic atraumatic coronary artery bypass (EACAB) grafting. Material and methods This prospective observational study covered 705 consecutive patients who underwent EACAB between April 1998 and December 2010. Quality of life was assessed in a follow-up of 2132 ±1313 days among 482 subjects using the WHOQoL-BREF questionnaire as an objective tool and the Likert scale as a more subjective method. Results There was good agreement between a 5-step Likert scale and a 5-step BREF Q1 (‘overall quality of life’) and Q2 (‘general health’) with a concordance correlation coefficient of CCC = 0.64 (95% CI: 0.58–0.69) and CCC = 0.49 (95% CI: 0.43–0.55), respectively. There was also a statistically significant correlation between answers reported using the Likert scale and all domains of BREF: physical health (R = 0.54, p < 0.001), psychological health (R = 0.56, p < 0.001), social relationships (R = 0.45, p < 0.001) and environment (R = 0.56, p < 0.001). Conclusions The Likert scale is useful in QoL assessment in patients after minimally invasive coronary surgery. This simple and easy-to-use screening method may be used interchangeably with a more reliable but also more complex questionnaire tool.

Del Nido cardioplegia – what is the current evidence?

Del Nido cardioplegia is believed to be both clinically and economically efficient. The interest in this myocardial protection method has been continuously growing. However, the evidence is not clear. The article summarizes recent reports regarding del Nido cardioplegia.

Surgical removal of entrapped guidewire fragment following direct circumflex artery angioplasty and stenting

We present a case of a 64-year-old man with coronary artery disease, who underwent a percutaneous coronary intervention of the circumflex artery. As the guidewire was being withdrawn from the target vessel, it became entrapped by the structure of the previously implanted stent. Attempts to retrieve the foreign body were unsuccessful. Changes in electrocardiogram were observed during the procedure, and the level of cardiac biomarkers increased within the next 24-hours. The patient was admitted to the Cardiac Surgery Department. Remnants of the foreign body were removed under visual control using extracorporeal circulation, and coronary artery bypass grafting was performed. Treatment options and outcomes are discussed.

Isolated High-Grade LAD Stenosis: A Primary Stenting Or Endoscopic Atraumatic Coronary Artery Bypass. Five Year Clinical Outcome: 7

8:12 A – 8:24 AM 2 Videothoracoscopic Resection of Benign Neurogenic Tumors Of The Posterior Mediastinum Paola Ciriaco, Gianpiero Negri, Alessandro Bandiera, Monica Casiraghi, Luca Ferla, Lucia Torracca, Piero Zannini Thoracic Surgery, Cardiac Surgery, University Vita-Salute and Scientific Institute H San Raffaele, Milan, Italy 8:24 A – 8:36 AM 3 Computer Assisted Stapling For Anatomical Lung Resection; Experience With 100 Consecutive Cases Wickii T. Vigneswaran, Charles Gruner Surgery, University of Chicago, Chicago, IL, USA, Surgery, Loyola University Medical Center, Maywood, IL, USA