Predrag S. Milojević

Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up

BackgroundThere is ongoing debate regarding the efficacy of the radial artery (RA) as an aortocoronary conduit, with few solid data regarding long-term clinical results. We sought to determine if the use of the RA as the second arterial conduit, beside left internal thoracic artery (LITA), would improve long-term clinical outcome after CABG as compared to saphenous vein graft (SVG).MethodsBetween March 2001 and November 2003, 200 patients underwent isolated CABG and were randomized in 1:1 fashion to receive either LITA and RA grafts or LITA and SVGs. The primary end point was composite of cardiovascular mortality, non-fatal myocardial infarction and need for repeat myocardial revascularization (either surgical or percutaneous).ResultsThere was no significant difference in absolute survival, with 12 deaths in each group during the study period (log ranku2009=u20090.01, pu2009=u20090.979). There were 3 and 2 cardiac deaths in RA and SVG groups, respectively. There was no difference in long-term clinical outcome between the groups (log ranku2009=u20090.450, pu2009=u20090.509). Eleven patients in RA group had one or more non-fatal events; 7 patients suffered a myocardial infarction, 9 patients underwent percutaneous coronary angioplasty, and 1 patient required redo coronary surgery. Likewise, 13 patients in SVG group had non-fatal event; 7 patients had myocardial infarction, 13 patients had percutaneous coronary intervention and 3 patients required redo coronary surgery. Angiograms were performed in 23 patients in RA group (patency rate 92xa0%) and 24 in SVG group (patency rate 86xa0%) (pu2009=u20090.67).ConclusionIn this small randomised study our data indicate that there is no difference in the 8xa0year clinical outcomes in relatively young patients between those having a RA or a saphenous vein graft used as a second conduit, beside LITA, for surgical myocardial revascularisation.

Impact of concomitant aortic regurgitation on long-term outcome after surgical aortic valve replacement in patients with severe aortic stenosis

BackgroundPrognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality.MethodsStudy group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR.ResultsPatients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality.ConclusionOur data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.

Simultaneous hybrid carotid stenting and coronary bypass surgery versus concomitant open carotid and coronary bypass surgery: a pilot, feasibility study

OBJECTIVESnConcomitant carotid and cardiac surgery carries an increased perioperative morbidity and mortality risk. Whether the hybrid procedure of carotid artery stenting (CAS) and coronary bypass surgery decreases the risk of stroke and other complications is still unknown. The aim of this study was to assess early outcomes after simultaneous hybrid CAS and coronary bypass grafting versus open concomitant carotid and coronary bypass surgery.nnnMETHODSnWe included 20 patients in this study. According to the protocol, all the patients were divided into two groups: Group 1 (10 patients) with hybrid CAS and coronary bypass surgery and Group 2 (10 patients) with concomitant carotid and coronary surgery. Different preoperative, intraoperative and postoperative variables were compared. The primary end point was combined incidence of stroke and death 30 days after surgery or during initial hospitalization. The secondary end points were myocardial infarction, atrial fibrillation, blood loss and need for blood transfusion and duration of intensive care unit and hospital stay.nnnRESULTSnGroups 1 and 2 were similar in preoperative characteristics including age (65.3 ± 6.8 vs 70.7 ± 7.0, P = 0.191) New York Heart Association class (2.3 ± 0.5 vs 1.8 ± 0.7, P = 0.218), EuroSCORE (2.8 ± 2.0 vs 3.6 ± 2.3, P = 0.547), the degree of carotid stenosis (79 ± 12 vs 87 ± 13%, P = 0.224) and average left ventricular ejection fraction (44.3 ± 12.4 vs 43.4 ± 13.3%, P = 0.896). Also, the groups did not differ in intraoperative variables with an exception of extracorporeal circulation time (65.7 ± 14.1 vs 90.0 + 17.4 min, P = 0.023), which was significantly shorter in Group 1. Although rare, and without significant difference, primary end point occurred only in Group 2 (1 stroke and 1 death, 20%). There was no difference in the duration of mechanical ventilation, need for transfusion and duration of intensive care unit and hospital stay between the two groups.nnnCONCLUSIONSnAlthough limited by a small sample size, our results show that the hybrid procedure of carotid stenting and coronary surgery might be a good therapeutic option but further extended studies are needed to assess its real value.

Off-pump myocardial revascularization using the Octopus tissue stabilizer system.

Off-pump coronary artery bypass surgery (OPCAB) has changed the approach to contemporary coronary surgery. Development of new surgical devices and techniques has reduced morbidity and mortality during off-pump surgery. From March 2000-April 2002, a total of 136 patients underwent open heart surgery using off-pump technique and fast-track anesthesia at Dedinje Cardiovascular Institute. Octopus Medtronic coronary stabilizer was used for stabilization of targeted vessel. Arterial grafts were used 169 times and saphenous vein 69 times. Average number of anastomoses was 1,830,73 per patient. One patient (0.74%) died. Three patients (2.21%) underwent surgery revision due to postoperative bleeding and one (0.74%) because of graft dysfunction. Perioperative myocardial infarction was registered 2 times (1.47%), pneumothorax 3 times (2.21%), postoperative arrhythmias 11 times (8.09%), transitory ischemic attack once (0.74%) and deep wound infection once (0.74%). Twelve patients (8.82%) required prolonged inotropic support. Angiographies early revealed patent grafts in 8 patients (5.88%). OPCAB is a safe and effective alternative approach to coronary artery revascularization. Use of coronary stabilizer has improved the safety and quality of OPCAB surgery.

Evaluation of Radial Artery Atherosclerosis by Intravascular Ultrasound

We read with great interest the article by Moon et al published in Angiology. The radial artery is increasingly used as conduit in coronary surgery. The extent of preexisting atherosclerosis determines the suitability of radial artery usage as graft in cardiac surgery. We acknowledge the authors’ contribution to existing literature about the relationship between established risk factors (male gender, age, hypertension, etc) and the extent of atherosclerotic plaques in the radial artery. In our opinion, the concept of evaluation of radial artery atherosclerosis by intravascular ultrasound (IVUS), based on transradial approach, has not much appeal to most surgeons due to several reasons:

High thoracic epidural anesthesia for coronary artery bypass graft surgery

Introduction High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympathetic blockade. Effects of high thoracic epidural anesthesia Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity. Results of clinical studies Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress. High thoracic epidural anesthesia technique The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended. Conclusion There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.

Correlation of structural defects in the ascending aortic wall to ultrasound parameters: benefits for decision-making process in aortic valve surgery

BackgroundHistopathological changes in the ascending aorta wall in patients with severe tricuspid aortic valve (TAV) stenosis were graded and correlated to echocardiographic parameters. Objective was to associate threshold echocardiographic values with structural defects in the ascending aorta providing a tool to improve decision-making process in cases when simultaneous aortic valve replacement (AVR) and ascending aorta replacement is considered.MethodsBiopsies from 108 TAV stenosis patients subjected to AVR were graded into three grades according to severity of aortic wall changes. Echocardiographic parameters obtained preoperatively and correlated to grade, age, gender and risk factors, were diameters of ventriculo-aortic junction (AA), sinus Valsalva (SV), sinotubular junction (STJ), the largest diameter of the visualized ascending aorta (AscA) as well as indexes: sinus Valsalva (SVI), sinotubular junction (STJI), AscA/AA and STJ/AA.ResultsTwo echocardiographic parameters portrayed grades with statistical significance: STJ (Fu2009=u20095.417; pu2009=u20090.006 (pu2009<u20090.05)) and AscA (Fu2009=u20093.924; pu2009=u20090.023 (pu2009<u20090.05)). By using multiple predictors in the setting of Regression analysis, statistically significant differences among grades were reached for AA, SV, STJ, AscA and SVI. With further ROC curves analysis, threshold values for different grades were recognized. Grade 2 is identified in patients with AscAu2009>u20093.3xa0cm, while Grade 3 is identified in patients with values of AscAu2009>u20093.5xa0cm, STJu2009>u20092.9xa0cm and STJIu2009>u20091.ConclusionsHemodynamic stress induced by TAV stenosis leads to elastic lamellae disruption in the aortic wall. Those changes could be graded and correlated with echocardiographic parameters of the aortic root and ascending aorta, providing a tool for decision to replace ascending aorta concomitantly with AVR.

Comparison of the left ventricular apex versus other arterial cannulation sites for the operative management of acute type A aortic dissection

The selection of the arterial inflow site for cardiopulmonary bypass during surgical treatment of patients with acute aortic dissection remains a very important issue. Several arterial cannulation sites, including left ventricular apex, were popularized over the years.

Innominate artery reconstruction during emergent surgery for acute aortic dissection

Case description This is a case of acute aortic dissection with multiple tears, occluding innominate artery and causing brain and right hand malperfusion. Patient underwent successful emergent surgery in deep hypothermic circulatory arrest with antegrade cerebral protection for complete replacement of innominate artery and hemiarch. Complete innominate artery was replaced during cooling period on 22°C.

Long-term follow-up of left ventricular systolic function and functional status following Bentall procedure

Background Data are scarce on long-term effects of Bentall procedure on left ventricular systolic function and functional status. Aim was to assess long-term effects of Bentall procedure on left ventricular (LV) systolic function and functional status. Methods Study group consisted of 90 consecutive patients who were operated using elective Bentall procedure for the aneurysm of the ascending aorta and aortic valve disease from 1997 to 2003 in a single tertiary care center. Patients were followed for eight years for mortality, LV ejection fraction and volume indices, as well as functional capacity as assessed by NYHA class. Echocardiographic measurements were made according to the recommendations given by the American Society of Echocardiography. Results Study group consisted of 71 male and 19 female patients, mean age 54+/-10 years. There were no operative deaths. Survival rate was 73.3% during eight-year follow-up (11 cardiac and 13 non-cardiac deaths). Echocardiography was performed before index procedure and after 96 +/-9 months. Statistically significant improvement in the LV ejection fraction was noted at follow-up examinations as compared to preoperative values (49.4+/-10.2% vs 42.5 +/-10.9%, respectively, p<0.0001). Similarly, statistically significant reduction in the LV end-systolic (36.4+/-8 ml vs 59.2+/-29.1 ml, respectively, p<0.0001) and end-diastolic volumes (70.7+/-18.1 ml vs 101.4+/-32.1 ml, respectively, p<0.0001) were observed. NYHA class improved from baseline during the follow-up (3.1+/-0.8 vs 1.7+/-1.1, respectively, p<0.0001). Univariate analysis identified ejection fraction on admission and the presence of postoperative complications as predictors of long-term LV ejection fraction. Conclusion Bentall procedure significantly improves long-term LV systolic function and functional status.