Paul A. Pirundini

Early results of a comprehensive operative and perfusion strategy to attenuate the incidence of adverse neurological outcomes in on-pump coronary artery bypass grafting (CABG) patients.

Adverse neurological events, both focal (Type I) and non-focal (Type II), have been appreciated in postoperative on-pump coronary artery bypass grafting (CABG) patients for many years. Advanced age is a significant risk factor for adverse neurological events following CABG surgery. With full knowledge that our elderly population of patients was at high risk for these untoward neurological events, we adopted a comprehensive operative and perfusion strategy in an attempt to attenuate the incidence of these complications. Our strategy included efforts to minimise the number of emboli generated during the operation, avoid cerebral hypoperfusion, and attenuate the systemic inflammatory response. From 15 August 2002 to 31 December 2005, we performed 355 on-pump CABG operations. The incidence of Type I focal injury was 0/355 (0%), the incidence of Type II non-focal injury was 9/355 (2.5%), and postoperative mortality was 2/355 (0.6%). These results compared favorably to the results predicted by the Society of Thoracic Surgeons’ (STS) model, and may suggest efficacy.

Coronary Endarterectomy or Patch Angioplasty for Diffuse Left Anterior Descending Artery Disease

Background Coronary endarterectomy and patch angioplasty for the left anterior descending (LAD) artery have been shown to be effective adjunct techniques to surgical revascularization for severe coronary lesions. The objective of this study is to review the short‐ and long‐term results of these two methods in our institution. Methods We retrospectively reviewed 166 consecutive patients who underwent internal thoracic artery grafting to the LAD, with either adjunct endarterectomy (95 patients) or patch angioplasty (71 patients) between 2002 and 2014. We compared the early and late outcomes between groups. Results The endarterectomy patients were older than the patch angioplasty patients (71 vs. 67 years, p = 0.007) and had lower rates of recent myocardial infarction (25% vs. 45%, respectively, p = 0.008). Median pulmonary bypass times and aortic cross clamp times were significantly longer in the endarterectomy group compared with the patch angioplasty group by 47 minutes (p < 0.001) and 42 minutes (p < 0.001), respectively. Median follow‐up time was 6.9 years. No significant differences in operative mortality, perioperative myocardial infarction, and long‐term survival were found. Freedom from percutaneous coronary intervention at 1 and 5 years was significantly higher in the endarterectomy group compared with the patch angioplasty group (p = 0.002). Conclusions Endarterectomy and patch angioplasty are comparable methods to reach complete revascularization for highly selected patients with diffuse atherosclerotic disease in the LAD. Compared with patch angioplasty, complete extraction of the atherosclerotic plaque with an endarterectomy leads to similar short‐term outcomes and long‐term survival while significantly reducing the need for further interventions in the future.

Trans-catheter aortic valve replacement program in a community hospital – Comparison with US national data

Symptomatic aortic stenosis remains a surgical disease, with aortic valve replacement resulting in symptom reduction and improvement in survival. For patients who are deemed a higher surgical risk, Transcatheter aortic-valve replacement (TAVR) is a viable, less invasive and increasingly common alternative. The study compares early outcomes in patients treated within one year of the commencement of TAVR program in a community hospital against outcomes of TAVR patients from nationwide reported data (Society of Thoracic Surgeons/ American College of Cardiology TVT registry). Preoperative characteristics and standardized procedural outcomes of all patients who underwent TAVR in Cape Cod Hospital between June 2015 and May 2016 (n = 62, CCH group) were compared using standardized data format to those of TAVR patients operated during the same time period in other centers within the United States participating in the STS/ACC TVT Registry (n = 24,497, USA group). Most preoperative patient characteristics were similar between groups. However, CCH patients were older (age≥80 years: 77.4% versus 64.3%, p = 0.032) and more likely to be non-elective cases (37.1% versus 9.7%, p<0.001). All 62 TAVR procedures in CCH were performed in the catheterization laboratory unlike most (89.7%) of the procedures in the USA group that were performed in hybrid rooms. A larger proportion of patients in the USA registry underwent TAVR under general anesthesia (78.2% vs.37.1%, P<0.001). Early aortic valve re- intervention rate was 0/62 (0%) in the CCH group VS. 74/ 24,497 (0.3%) in the USA group. In hospital mortality, which was defined as death of any cause during thirty days from date of operation, (CCH: 0% vs. USA: 2.5%, p = 0.410) and occurrence of early adverse events (including postoperative para-valvular leaks, conduction defects requiring pacemakers, neurologic and renal complications) were similar in the two groups. The study concludes that with specific team training and co-ordination, and with active support of experienced personnel, high risk patients with severe aortic valve stenosis can be managed safely with a TAVR procedure in a community hospital.

Restoration of the coagulation cascade on CPB: a case report:

Coagulopathy can sometimes be observed when CPB times are prolonged. Correction of coagulopathy post CPB can present the surgical team with a number of challenges, including right ventricular volume overload, hemodilution, anemia and excessive cell salvage with further loss of coagulation factors. Restoration of the coagulation cascade on CPB may help to avoid these issues. This case report is of a 64-year-old male with a delayed diagnosis of aortic dissection. The patient presented to the cardiac surgery operating room with hepatic and renal shock/failure, with the resulting coagulopathy. The described technique is representative of a technique that we sometimes employ to restore the clotting mechanism before separating from bypass.

Unusual Appearance of Clot in the Left Atrium

73-year-old man had experienced episodes of palpitations for more than 1 year. The palpitations ccurred when the patient was in a supine position and hey were not related to exertion. They were not associted with syncope or chest pain. The cardiac workup ncluded a Holter monitor that showed a predominantly inus rhythm with premature atrial contractions and everal episodes of nonsustained atrial tachycardia. A ransthoracic echocardiogram demonstrated a left atrial ass. A transesophageal echocardiogram confirmed the resence of an echodensity attached to the posterior spect of the left atrium that measured 1.4 1.5 cm with alcium in the mass (Fig 1). There was no evidence of hrombus in the left atrium or its appendage, no mitral alve regurgitation, and no interatrial septal communiation. Preoperatively the patient underwent a cardiac atheterization that showed significant left anterior decending and circumflex coronary artery disease.