Mikael Arbeus

Milrinone Improves Diastolic Function in Coronary Artery Bypass Surgery as Assessed by Acoustic Quantification and Peak Filling Rate: A Prospective Randomized Study

OBJECTIVE To compare the effects of a bolus dose of milrinone, 50 microg/kg, to placebo on diastolic function (active relaxation) in patients undergoing on-pump coronary artery bypass grafting (CABG). DESIGN Prospective, randomized, double-blind, placebo-controlled study. SETTING University hospital. PARTICIPANTS Twenty-four patients with stable angina and left ventricular ejection fraction >30%, scheduled for elective CABG using cardiopulmonary bypass (CPB), were included. INTERVENTION Patients were randomized to receive either 50 microg/kg of milrinone (n = 12) or placebo (n = 12) after aortic declamping. MEASUREMENTS AND MAIN RESULTS The diastolic function of the left ventricle (LV) was measured as peak filling rate (dA/dt [maximal diastolic area change over time]) with transesophageal echocardiography (TEE) using acoustic quantification (AQ) before CPB and 10 minutes after termination of CPB. The normalized peak filling rate (dA/dt)/EDA was also calculated. Active relaxation was statistically significantly increased in the milrinone group compared with the placebo group after CPB. CONCLUSION Patients undergoing CABG surgery and treated with milrinone after aortic declamping had better diastolic function following cardiopulmonary bypass.

Graft patency is associated with higher health-related quality of life after coronary artery bypass surgery†

Objectives The objective of this study was to investigate whether graft patency was associated with higher health-related quality of life in coronary artery bypass grafting patients and to compare this study with the general Swedish population. Methods Patients were included from 3 randomized trials and 1 prospective cohort trial. The generic health-related quality of life instrument, EQ-5D (VAS and index) was used. Graft patency was assessed with computed tomography angiography. Patients were divided into 2 groups according to the number of occluded distal anastomosis: Group I with no to 1 occlusion ( n  = 209) and Group II with 2 to 4 occlusions ( n  = 24). Results Two hundred and thirty-three patients underwent computed tomography angiography at a mean of 7.5 (1-18) years post-operatively. The mean difference in EQ-VAS and EQ-5D index between Groups II and I after model adjustment was -19.8 (95% CI -25.3 to -14.3; P  < 0.001) and -0.13 (95% CI -0.19 to -0.08; P  < 0.001), respectively. The EQ-5D index for the study population was similar compared with the Swedish population, 0.851 and 0.832, respectively, with an effect-size of 0.112 (trivial). The EQ-5D index of the study population was higher compared with the ischemic heart disease group in the Swedish population, 0.851 vs 0.60, with an effect-size of 0.999 (large). Conclusions Graft patency was associated with higher health-related quality of life in coronary artery bypass patients. This patient group reported similar function and wellbeing compared to the general Swedish population and better health status than those in the same disease group in the general population. Clinical registration number Clinicaltrials.gov: NCT02547194 and the Research and Development registry in Sweden: 167861.

The no-touch saphenous vein graft in elderly coronary bypass patients with multiple comorbidities is a promising conduit to substitute the left internal thoracic artery

Objectives We investigated the patency rates of no‐touch saphenous vein grafts anastomosed to the left anterior descending artery compared with the left internal thoracic artery. Further, we compared the patency of no‐touch vein grafts to the left anterior descending artery with the patency of no‐touch vein grafts to other coronary arteries. Methods Of 2635 consecutive patients undergoing coronary artery bypass grafting between 2003 and 2008, 168 (6.3%) were given at least a saphenous vein graft to the left anterior descending artery to avoid harvesting complications in high‐risk patients or in response to a left internal thoracic artery injury. A total of 97 patients were consecutively included after informed consent. A clinical examination and computed tomography angiography were performed on 91 patients at a mean of 6 (4‐9) years. Results The mean age of patients was 75.6 ± 8.5 years. Postoperatively, 88.7% of patients (86/97) were free of angina. The 91 examined patients had 163 grafts with 286 distal anastomoses. Crude patency, according to distal anastomoses, was 94.4% (270/286). The patency of single versus sequential no‐touch vein grafts to the left anterior descending artery was 98% (50/51) versus 92.5% (37/40). The total patency rate was 95.6% (87/91), similar to the reported patency rate for the left internal thoracic artery. The no‐touch grafts to the left anterior descending artery versus other coronaries had a patency of 95.6% (87/91) versus 93.8% (183/195), a high similarity confirmed by an equivalence analysis. Conclusions In elderly coronary bypass patients with multiple comorbidities, a no‐touch saphenous vein graft is a promising substitute for the left internal thoracic artery.

Recent Strategies to Improve Graft Performance in Patients Undergoing Coronary Artery Bypass Surgery. Are Best Results Achieved by Improved Surgical Techniques of Graft Preparation

The patency rate of the saphenous vein (SV) used as a graft in patients undergoing coronary artery bypass surgery (CABG) is poor, with 15-25% grafts occluding within 1 year and over 50% patients requiring further (redo) surgery within 10 years.1 In order to investigate the strategies to reduce vein graft failure in patients undergoing CABG, the underlying pathology of the disease must first be established. The high prevalence of coronary heart disease in Western society has prompted surgeons to develop procedures to improve myocardial blood flow, and subsequently relieve the symptoms of angina pectoris along with other myocardial crises.2 One of the most significant advances in vascular surgery was the finding that venous conduits could be used as replacements for atherosclerotic arteries. Following the work of Alexis Carrel at the turn of the century, a venous graft was first used in 1906 to replace a popliteal aneurysm.2 Promising experimental results encouraged surgeons to apply this method to the coronary vessels. By the 1950s, at the Cleveland Clinic, Favaloro et al. had treated numerous cases of peripheral and renal artery reconstruction with venous conduits and employed this procedure in coronary vessels.3 Research efforts by Favaloro4 led to the development of CABG, a technique which has been used for almost four decades. The great SV of the leg is the conduit of choice for three main reasons. First, it is expendable as deeper vessels maintain blood flow to superficial tissues after its removal. Second, the extensive length of this vein allows for multiple grafts, and finally, its superficial position renders it easily accessible. A 10-year follow-up recatheterization of Favarolo’s first operation showed that both the graft and the bypassed right coronary artery remained patent.3 Such promising results reshaped the history of cardiac surgery and led to the rise of surgical revascularization in the treatment of ischemic heart disease.

Dacron Graft Intussusception Technique for Treatment of Type A Aortic Dissections: Technical Notes and Preliminary Results

Introduction Optimal surgical management for acute type A aortic dissection (AAAD) remains unclear. The in-hospital mortality rate is still high (15%), and the intraoperative bleeding is an independent risk factor for hospital mortality. Objective The aim of our study was describe a new method for aortic anastomosis in the repair of AAAD and report the hospital mortality and bleeding complications. Methods Between January 2008 and November 2014, 24 patients, 16 male, median age 62 years, underwent surgical treatment of AAAD. The surgical technique consisted of intussusception of a Dacron tube in the dissected aorta, which is anastomosed with a first line of 2-0 polyester everting mattress suture and a second line of 3-0 polypropylene running suture placed at the outermost side. Open distal anastomosis was performed with bilateral selective antegrade cerebral perfusion in 13 (54.1%) patients. Results Cardiopulmonary bypass and aortic clamping time ranged from 75 to 135 min (mean=85 min) and 60 to 100 min (mean=67 min), respectively. The systemic circulatory arrest ranged from 29 to 60 min (mean=44.5 min). One (4.1%) patient required reoperation for bleeding, due to the use of preoperative clopidogrel. The postoperative bleeding was 382-1270 ml (mean=654 ml). We used an average of 4.2 units of red blood cells/patient. There were two (8.3%) hospital deaths, one due to intraoperative bleeding and another due to mesenteric ischemia. The average length of stay in the intensive care unit and hospital was 44 hours and 6.7 days, respectively. Conclusion This new method for surgical correction of AAAD was reproducible and resulted in satisfactory clinical outcomes.