Paul Stelzer

Coronary Artery Bypass Grafting Using the Radial Artery Clinical Outcomes, Patency, and Need for Reintervention

Background— Radial artery (RA) grafts are an attractive second arterial conduit after the left internal thoracic artery (LITA) for coronary artery bypass graft (CABG) surgery. However, long-term outcomes and the need for subsequent reintervention have not been defined. Methods and Results— We performed a retrospective cohort study of our single institutions 16-year experience with 1851 consecutive patients (average age, 58 years; 82% men, 36% diabetic) undergoing primary, isolated CABG with the LITA, RA, and saphenous vein as needed. Average grafts per patient were 3.8, with 2.4 arterial grafts per patient. Survival was determined using the Social Security Death Index. Grafts were nonpatent if they had a >50% stenosis, a string sign, or were occluded. Five patients (0.3%) died in hospital and 0.8% had a myocardial infarction, 1.1% a stroke, and 0.6% renal failure. Kaplan-Meier–estimated 1-, 5-, 10-, and 15-year survival was 99%, 96%, 89%, and 75%, respectively. Of the cohort, 278 symptomatic patients underwent cardiac catheterization at our institution an average of 5.0±3.8 years (range, 0.1–12 years) after CABG. Overall RA (n=420 grafts) patency was 82% and SV (n=364 grafts) patency, 47% (P<0.0001). LITA (n=287 grafts including 9 sequential grafts) patency was 85% and right internal thoracic artery (n=15 grafts) patency was 80% (P=0.6). RA patency was not different from LITA patency (P=0.3). Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively. Conclusions— RA grafting is a highly effective revascularization strategy providing excellent short and long-term outcomes with very low rates of reintervention. RA patency is similar to LITA patency and is much better than SV patency. RA grafting should be more widely utilized in patients undergoing CABG.

Hypotension with ventricular pacing: An atrial vasodepressor reflex in human beings

Hypotension with ventricular pacing has generally been attributed to loss of atrial transport, but it has been suggested that atrial vasodepressor reflexes may play a role. To study this, constant rate atrial and ventricular pacing was performed in 20 supine patients 24 to 36 hours after surgical coronary artery bypass or aortic valve replacement. The pulmonary capillary wedge tracing was examined for the presence or absence of cannon A waves during ventricular pacing in each patient. Thirteen patients had cannon A waves (group I) and seven did not (group II). Ten of the 13 patients with cannon A waves had ventriculoatrial conduction compared with only 2 of 7 patients without cannon A waves. There was a nonsignificant trend toward an association between cannon A waves and ventriculoatrial conduction (p = 0.1). Stroke volume index decreased in both groups when patients were changed from atrial to ventricular pacing. In the patients with cannon A waves, stroke volume index decreased from 31.2 to 26.3 cc/min per m2 (p less than 0.001) and from 31.2 to 25.0 cc/min per m2 (p less than 0.001) in those without cannon A waves (group I versus group II, p = NS). However, mean systemic blood pressure decreased only in patients with cannon A waves (99.4 to 85.9 mm Hg [p less than 0.001] versus 101.8 to 100.9 mm Hg [p = NS]) in those without cannon A waves (group I versus group II, p less than 0.001). Hypotension in patients with cannon A waves was caused by inhibition of the normal reflex increase in systemic vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures

BACKGROUND The initial experience with left atrial esophageal fistula (LAEF) secondary to atrial fibrillation (AF) ablation procedures revealed a near-universal mortality. A comprehensive description of the principles of LAEF repair in the modern era and its resulting impact on morbidity and mortality are lacking in the literature. OBJECTIVE To describe the presentation, surgical management, and outcomes of patients with LAEF. METHODS A retrospective cohort analysis of 29 patients was performed, including previously unpublished cases of surgically repaired LAEF from 4 institutions (n = 6), and all published cases of surgically repaired (n = 16) or stented (n = 7) LAEF. RESULTS The mean age was 55 ± 13 years, and 75% were men who were undergoing radiofrequency energy catheter ablation (n = 26), cryoablation (n = 1), high-intensity focused ultrasound ablation (n = 1), and surgical mini-MAZE procedure (n = 1) and presented 30 ± 12 days postablation procedure. Overall, 55% of the patients receiving an intervention for LAEF died (41% surgical repair; 100% stent). Patients who did not receive primary esophageal repair were more likely to experience postoperative complications, including mediastinitis, need for percutaneous endoscopic gastrostomy (PEG) feeds, esophageal stent, or death (P = .05). In addition, interposing tissue between the repaired esophagus and the left atrium resulted in fewer postoperative complications (P = .02). CONCLUSIONS While improved relative to initial reports, mortality associated with LAEF remains high after corrective intervention. Primary esophageal repair with the placement of tissue between the repaired esophagus and the left atrium may result in lower morbidity and mortality.

The Ross Procedure: State of the Art 2011

The purpose of this paper is to review the current literature and practice of the Ross concept of using the autologous pulmonary valve to replace a diseased aortic valve. The potential advantages and disadvantages of these operations will be evaluated in the context of alternative options and relative risks. The different surgical techniques of subcoronary and full root methods will be discussed and important technical aspects reviewed. Long-term outcomes will be described to the extent these are available, including recent publications describing a survival advantage for the Ross. Brief discussions will be presented regarding hemodynamics, child-bearing, endocarditis, and the use of the Ross in pediatric patients as well as biological adaptability of the living pulmonary autograft.

Percutaneous Closure of Left Ventricular Pseudoaneurysm

The risk of rupture of a left ventricular (LV) pseudoaneurysm ranges from 30% to 45% in the first year. Open surgical repair carries high mortality related to anatomic complexity and patient comorbidities. Percutaneous closure may offer a viable alternative to surgical intervention in this cohort. Herein, we describe 3 unique cases of transcatheter LV pseudoaneurysm closure.

3D thinking for mini-AVR.

Minimally invasive approaches to aortic valve replacement have been in use now for over 15 years. The most popular have been the partial upper sternotomy ([1,2][1]) and the right second interspace anterior thoracotomy ([3,4][2]). A vertical right parasternal approach that was used early on has been

Assessment of Surgical Septal Myectomy by Real-Time 3-Dimensional Transesophageal Echocardiography

The left ventricular outflow tract (LVOT) is a 3-dimensional structure. Consequently, 2-dimensional transesophageal echocardiography (2D TEE) will never be able to truly assess this structure’s dimensions during the cardiac cycle. While Doppler technology can provide the imager with indirect information regarding the adequacy of septal resection (reduction in pressure gradient, loss of turbulent flow distal to the obstruction), only 3-dimensional imaging is capable of directly quantifying the adequacy of resection. The authors report the use of realtime 3-dimensional TEE (RT 3D TEE) imaging to assess the adequacy of surgical septal myectomy.

Balloon in the left ventricular outflow tract: A surgical technique for the calcified unclampable aorta with aortic insufficiency

Calcified ascending aorta with severe aortic insufficiency (AI) is a unique problem. Clamping a heavily calcified aorta carries a major risk of stroke. To achieve adequate systemic cooling for deep hypothermic circulatory arrest (DHCA) without aortic clamping in the setting of severe AI is a difficult challenge. In such a scenario, if ventricular fibrillation occurs, the left ventricle (LV) can distend despite the LV vent, which is typically placed through the right superior pulmonary vein (RSPV). This can lead to subendocardial ischemia and myofibrillar disruption, with subsequent myocardial dysfunction. Ventricular fibrillation can be delayed or sometimes avoided by gradual cooling. Retrograde warm blood perfusion through the coronary sinus to keep the heart beating has been described. A pulmonary arterial vent can be placed in addition to that in the RSPV; however, if and when there is excessive LV distention, one is forced to arrest the circulation before the desired temperature has been achieved. We describe a technique to prevent LV distention by using an inflated balloon in the LV outflow tract (LVOT), thereby allowing continuation of systemic cooling and coronary perfusion on cardiopulmonary bypass until the goal temperature for DHCA has been achieved.

Magnetic Resonance Imaging Diagnosis of Left Atrial Abscess After Ablation of Atrial Fibrillation

We report a 52-year-old patient with a late presentation of a fistula that occurred after catheter ablation for atrial fibrillation. A secondary left atrial wall abscess was diagnosed by upper endoscopy and cardiac magnetic resonance imaging. Emergency operative repair was successful, with no adverse cardiac or gastrointestinal sequelae.

Repair of an Aortic Sinus Right Ventricular Fistula and Aortic Leaflet Disruption After a Stab Wound

A28-year-old man with no significant past medical history presented to an outside hospital after a stab wound to the right anterior chest. The patient underwent an emergent median sternotomy to treat tamponade from a perforated right ventricle. A primary repair of the ventricle was performed, chest tubes were placed, and the patient’s chest was closed. Postoperatively, while still at the outside hospital, transesophageal echocardiography demonstrated a presumably traumatic fistula from the right sinus of Valsalva to the right ventricle with a gradient of 50 mm Hg, and moderate aortic insufficiency (Fig 1). Additionally, a soft, continuous murmur was present in the right parasternal area. The patient was transferred for definitive surgery. A resternotomy was performed and aortobicaval bypass commenced. An oblique aortotomy revealed a 1 cm laceration at the base of the right sinus of Valsalva approximately 0.5 cm to the left of the right coronary ostium (Fig 2A, black arrow). Directly opposite this was an 8 mm laceration in the right aortic cusp (Fig 2B, black arrow) and a 2 to 3 mm laceration in the left aortic cusp (Fig 2C). There did not appear to be any injury to the left coronary sinus. Primary repair of the right sinus of Valsalva was performed with a double layer 6-0 Prolene, and the lacerations in both the right and left valve leaflets