Noriyuki Takashima

Off-pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Elderly Patients

BACKGROUND The purpose of the present study was to compare outcome in propensity score-matched patients, aged 70 years or greater, undergoing isolated off-pump coronary bypass surgery using a bilateral (BITA) or single (SITA) skeletonized internal thoracic artery. METHODS Of 912 consecutive patients undergoing isolated coronary bypass grafting (906 using the off-pump technique without emergent conversion to cardiopulmonary bypass), the 491 aged 70 years or greater undergoing off-pump skeletonized single (n=247) or bilateral (n=244) skeletonized internal thoracic artery grafting were retrospectively analyzed after excluding the 6 who were transferred to our hospital after receiving percutaneous cardiopulmonary bypass, the 72 who had only 1 target in the left coronary area, and the 343 aged less than 70 years. A total of 217 pairs were matched using propensity scores calculated from 9 preoperative factors (0.69). RESULTS The rate of postoperative complications was similar between the groups. The 5-year estimated survival free from overall death and cardiac event, respectively, in the BITA group versus the SITA group were 86.4%±3.2% versus 73.5%±3.9% (p=0.01) and 93.2%±2.7% versus 87.5%±3.0% (p=0.01). In multivariate Cox models, bilateral internal thoracic artery grafting was significantly associated with a lower risk of overall death (hazard ratio 0.56; 95% confidence interval 0.31 to 0.99; p=0.04) and cardiac event (hazard ratio 0.36; 95% confidence interval 0.15 to 0.88; p=0.03). CONCLUSIONS In elderly patients, off-pump in situ left-sided bilateral skeletonized internal thoracic artery grafting is associated with lower risk of overall death and cardiac event than single internal thoracic artery grafting and carries no increased operative risk.

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

BACKGROUND When 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. METHODS From 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]). RESULTS The 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. CONCLUSIONS Skeletonized GEA grafting to the right coronary artery system is better than SVG grafting in patients with left-sided bilateral internal thoracic arterial grafts.

Early and Long-Term Patency of In Situ Skeletonized Gastroepiploic Artery After Off-Pump Coronary Artery Bypass Graft Surgery

BACKGROUND There is at present no accurate figure for the long-term patency rate of the skeletonized gastroepiploic artery (GEA). METHODS From January 2002 to July 2012, 956 consecutive patients underwent isolated off-pump coronary artery bypass graft (OPCABG) surgery at our institution. Of these, the 424 who underwent GEA grafting and postoperative GEA graft evaluation were the subjects of the present study. Of these 424 subjects, 155 (36.6%) underwent long-term outpatient evaluation using multidetector computed tomography angiography. RESULTS No patient was converted from off pump to on pump surgery. Overall 30-day mortality was 0.5% (2 of 424). The overall early (4 to 21 days after surgery) patency rate of the skeletonized GEA was 98.2% (599 of 610 anastomoses). A total of 215 GEA anastomoses, including 55 sequential bypasses, were followed for long-term evaluation, of which 12, including three sequential bypasses, were found to be occluded. The overall patency rate in skeletonized GEA grafting over a mean follow-up period of 73 months was 94.4% (203 of 215). The cumulative patency rate of the skeletonized GEA was 97.8% at 30 days, 96.7% at 1 year, 96.0% at 3 years, 94.7% at 5 years, and 90.2% at 8 years after surgery. Multivariate Cox proportional hazard regression analysis showed that target vessel stenosis (p = 0.008, hazard ratio 0.086, 95% confidence interval: 0.014 to 0.53) was the only independent predictor of late graft occlusion. CONCLUSIONS We demonstrated an accurate long-term patency rate for the skeletonized GEA superior to that for pedicled GEA or saphenous vein graft. A low-grade degree of target vessel stenosis was the only risk factor for late GEA occlusion.

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

BACKGROUND Quadrangular 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. METHODS Between 2002 and 2009, 53 patients underwent posterior leaflet resection with mitral annuloplasty, including quadrangular resection in 24 and butterfly resection in 29. RESULTS The 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. CONCLUSIONS Butterfly 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

OBJECTIVE The 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. METHODS Of 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. RESULTS AF 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). CONCLUSIONS Preoperative CRP is independently associated with the occurrence of AF after isolated off-pump coronary bypass surgery.

Selective cerebral perfusion with mild hypothermic lower body circulatory arrest is safe for aortic arch surgery.

OBJECTIVES The antegrade selective cerebral perfusion (SCP) technique, which extends the safe time limit for arch surgery, has now gained acceptance. However, neither the optimal hypothermic temperature nor the optimal SCP flow rate has been clearly determined. METHODS From January 2008 to February 2012, a total of 105 patients underwent total arch replacement under a single surgeon (A.T.) at Shiga Medical University Hospital. The patients were 85 males and 20 females with a mean age of 73 years (range 41-88). The cause of the aneurysm was atherosclerosis in 90 patients and dissection in 15. Eighty-one patients with chronic lesion underwent elective surgery and 24 underwent emergent surgery. Univariate analysis of postoperative neurological dysfunction and early mortality was performed. RESULTS The mean operation time, cardiopulmonary bypass (CPB) time, coronary ischaemic time, lower body circulatory arrest (CA) time and SCP time were 277 ± 83 min, 164 ± 40 min, 92 ± 33 min, 58 ± 22 min and 95 ± 28 min, respectively. Thirty-day mortality occurred in 1 ruptured emergent case (1%). Hospital mortality (>30 days) occurred in 3 cases (3%), 2 due to multisystem organ failure following emergent rupture and the other to cerebrovascular accident in an elective surgery case. Permanent neurological dysfunction (PND) occurred in 3 patients (3%) and temporary neurological dysfunction (TND) also in 3 patients (3%). CONCLUSIONS SCP under mild hypothermia can be safely applied to aortic arch surgery and is associated with a low rate of hospital mortality and morbidity. However, prolonged SCP time is associated with incidences of postoperative neurological deficit.

Mid-term results for the use of the extended sandwich patch technique through right ventriculotomy for postinfarction ventricular septal defects †

OBJECTIVES Postinfarction ventricular septal defect (VSD) is a rare, but feared, complication after acute myocardial infarction. Although numerous techniques and materials have been used, the best technique has not yet been settled upon. We present a novel technique of VSD closure through the VSD via right ventricular (RV) incision and assess short- and mid-term outcomes. METHODS Between April 2008 and March 2012, 15 consecutive patients presenting with postinfarction VSD underwent surgical repair using this technique in our department. RESULTS Thirty-day mortality was 20% (3 patients). Two patients died from low cardiac output. No early complications related to the VSD repair were observed, such as shunt recurrence, severe septal dyskinesia or pseudoaneurysmal change in the left ventricular myocardium. The left ventricle was contracted well without mitral regurgitation. The mean follow-up period was 17 ± 15 months. The Kaplan-Meier estimate of 3-year cumulative survival is 76%. At the mid-term stage, one trivial residual leak was noted, but no patient required reoperation. RV function was within the normal range after the operation. CONCLUSIONS This method of VSD repair using right ventricle incision and trans-VSD approach is safe and simple and reduces the postoperative recurrence of VSD.

Risk factors for acute kidney injury in aortic arch surgery with selective cerebral perfusion and mild hypothermic lower body circulatory arrest

OBJECTIVES Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery. However, the incidence of AKI in patients undergoing total arch replacement (TAR) with selective cerebral perfusion (SCP) and mild hypothermic lower body circulatory arrest (mild HLBCA) with a tympanic temperature of 25°C remains unknown. We studied AKI incidence and associated risk factors, as defined by the Acute Kidney Injury Network (AKIN). METHODS We examined 116 consecutive patients with aortic arch aneurysm undergoing non-emergency TAR. Our surgical method is standardized to use systemic cooling of the tympanic membrane temperature to 25°C for circulatory arrest, followed by SCP and myocardial protection by cold blood cardioplegia. Anastomoses were sequentially constructed at the distal arch, the proximal root, the left sub-clavian artery, the left carotid artery and the right brachiocephalic artery. Bladder temperature was generally around 30°C at the start of lower body circulatory arrest (mild HLBCA) until reperfusion of the distal aorta. The incidence of AKI was investigated, with multivariate analysis of its risk factors. RESULTS The mean operation time, cardiopulmonary bypass (CPB) time, mild HLBCA time and SCP time were 270.6 ± 72.5, 151.0 ± 46.4, 53.1 ± 20.1 and 99.0 ± 28.4 min, respectively. Hospital mortality occurred in 2 cases (1.7%). AKI occurred in 50 cases (43.1%); of which, 2 cases required renal replacement therapy (RRT). However, AKI had subsided in 44 cases by discharge. For contemporary perspective, the incidence of AKI was 32.8% in off-pump coronary bypass grafting and 38.9% in aortic valve replacement. Multivariate analysis of risk factors for AKI identified chronic kidney disease (CKD) (eGFR <60 ml/min/1.73 m(2)) and mild HLBCA time >60 min. CONCLUSIONS Our method of TAR was associated with low mortality and low rate of kidney injury by discharge. However, prolonged mild HLBCA and preoperative CKD might need additional consideration.

Total arch replacement with selective antegrade cerebral perfusion and mild hypothermic circulatory arrest.

This article describes the surgical techniques demonstrated in our video, “Total arch replacement (TAR) with selective antegrade cerebral perfusion (SACP) and mild hypothermic circulatory arrest” (Video 1). Video 1 Total arch replacement with selective antegrade cerebral perfusion and mild hypothermic circulatory arrest The aortic arch is the most common location for the development of aortic aneurysms. These aneurysms are often located close to the brachiocephalic vessels, and atheromatous plaque and thrombus are often present both in the aneurysm and in the nearby aorta. In addition, the brachiocephalic branches, especially the left subclavian artery, frequently have atheromatous plaque at the orifices. Despite recent progress in endovascular treatments, mural thrombus and atherosclerotic debris in the aortic arch are frequently problematic. Therefore, endovascular repair cannot be considered as the first-line intervention for arch aneurysm without establishing secure preventive measures against atheroembolism caused by catheterization. The open replacement of the whole aortic arch with brachiocephalic vessel reconstruction using prosthetic grafts remains the gold standard procedure for the management of this condition. Historically, open aortic arch surgery for aortic arch aneurysm has been invasive. We believe that four factors make open arch repair difficult: (I) possible brain injury due to inadequate protection; (II) a deep, narrow operative field in the distal aorta and the left subclavian artery; (III) hemorrhage and transfusion; and (IV) possible myocardial damage due to prolonged ischemia. Therefore, we have used hypothermic circulatory arrest with SACP rather than other brain protective methods, and developed a method to optimize the operative field. Our procedure for arch aneurysm is simple and standardized. We use systemic cooling until 25 to 28 °C at tympanic membrane temperature, followed by SACP with balloon-tipped catheters and myocardial protection by intermittent retrograde blood cardioplegia. Anastomoses are sequentially constructed at the distal arch, the proximal root, the left subclavian artery, the left carotid artery, and the right brachiocephalic artery. Most of these procedures are routinely completed within 3 hours. Patients even over 80 years old can mobilise on the ward and resume oral diet on postoperative day one. Fast-tracked recovery is certainly achieved with this surgical procedure.

Off-pump coronary artery bypass grafting using skeletonized in situ arterial grafts

Skeletonization is an advanced technique of graft harvesting for coronary artery bypass grafting (CABG), and while it requires meticulous attention, it has many advantages. For example, skeletonization of internal thoracic artery (ITA) can minimize sternal ischemia and lower the risk of mediastinitis, and is longer and larger than pedicled ITA. In this article we describe the surgical techniques demonstrated in our video, which details our techniques of skeletonization of arterial grafts and off-pump coronary artery bypass (OPCAB) exclusively using these in situ grafts. Our method of right gastroepiploic artery (GEA) skeletonization has only three technical steps. The first step is to pass thin vessel loops under the GEA. The second step is to unroof the tissue surrounding the GEA. The last step is to seal and sever all the branches. Skeletonization of the GEA not only prevents vasospasm but also leads to GEA dilatation, and facilitates inspection and makes sequential anastomosis easier. Bilateral use of the skeletonized ITA and use of the skeletonized GEA can cover most coronary artery target sites without any manipulation of the ascending aorta. In our consecutive series of over 1,000 patients, the stroke rate was 0.5%. Our method helps to make the technique simple and secure in this technically demanding operation, and we believe that OPCAB with these grafts provides the best possible coronary revascularization.