Ramzi Ramadan

Nonpenetrating clips for coronary anastomosis

BACKGROUND A nonsuture clip technique (nonpenetrating titanium clips applied to everted tissue edges at high compressive forces) was used to perform coronary anastomoses in a clinical setting. METHODS Clipped coronary anastomoses were performed in 10 patients. The anastomoses incorporated the left internal mammary artery to the left anterior descending artery (n = 1) and the saphenous vein to the right coronary artery (n = 5), the posterior descending artery (n = 2), the diagonal artery (n = 2), and one vein-to-vein proximal anastomosis (n = 1). RESULTS The mean duration for completion of the anastomoses was 15 minutes (range, 7 to 20 minutes). This time was reduced from 20 minutes at the beginning of the clinical experience to 7 minutes for the last 3 patients. No technical complication was related to clip application and all patients had uneventful outcomes. Three anastomoses studied by coronary angiography were patent without stenosis. CONCLUSION The clipped anastomotic technique has a rapid learning curve, the same safety as suture methods, and the potential for facilitating endoscopic vascular reconstructions.

Thoracoscopic internal mammary artery harvesting: Technical considerations

BACKGROUND Technical details of thoracoscopic harvesting of the internal mammary artery (IMA) are reported. This procedure allows a complete dissection of the left IMA from its origin at the subclavian artery to the sixth intercostal branches with transection of all collateral branches. METHODS Between September 1995 and September 1996, thoracoscopic harvesting of the left IMA was performed on 32 patients who had undergone a minimally invasive coronary artery bypass grafting procedure. RESULTS There were no conversions to a standard approach because of an injury to the graft and no reoperations for bleeding. The mean duration of the IMA harvesting procedure was 58.7 minutes (range, 20 to 130 minutes). CONCLUSIONS This procedure enlarges the field of minimally invasive coronary artery bypass grafting techniques. The thoracoscopic harvest of the full length of the IMA allows the procedure to more closely replicate the open approach.

Transcatheter aortic valve implantation through carotid artery access under local anaesthesia

OBJECTIVES Trans-femoral and transapical are the most commonly used accesses for transcatheter aortic valve implantation (TAVI). However, when these approaches are unsuitable, alternative accesses are needed. We report a series of 19 patients undergoing TAVI through common carotid artery (CCA) access under local anaesthesia in order to assess its feasibility and safety. METHODS From November 2008 to September 2013, 361 patients underwent TAVI at our institution. Nineteen of them (14 men) with mean age 82.2 ± 6.2 years, EuroSCORE 25.2 ± 15.7, Society of Thoracic Surgeons score 11.9 ± 5.1 and with severe peripheral arteriopathy were unsuitable for usual approaches and underwent TAVI through CCA access under local anaesthesia. Preoperative computed tomography assessed suitable carotid artery anatomy. Common carotid cross-clamping test allowed verifying patients neurological status stability. An 18-Fr or 20-Fr sheath inserted into the CCA down into the ascending aorta was used for the delivery catheter. Valve implantation procedures were as usual. After sheath removal, the CCA was surgically purged and repaired. Feasibility and safety end points (VARC-2) were collected up to 30 days. RESULTS Transcarotid insertion of the delivery sheath was successful in all cases (8 right, 11 left) and accurate deployment of the device was achieved in 18 patients (4 Edwards SAPIEN XT and 14 Medtronic CoreValve). There was 1 intraoperative death by annulus rupture during preimplant balloon valvuloplasty, and 1 in-hospital death due to multisystem organ failure. There was no myocardial infarction, stroke or major bleeding. Third-degree atrioventricular block requiring pacemaker implantation occurred in 3 patients. No vascular access-site, access-related or other TAVI-related complication occurred. Echocardiography revealed good prosthesis functioning with none, mild and moderate paravalvular leak in, respectively, 8, 9 and 1 patients. Patient ambulation was immediate after TAVI and hospital stay was 4.6 ± 2.3 days. CONCLUSIONS TAVI through the CCA approach under local anaesthesia is feasible and safe. It allows continuous clinical neurological status monitoring with low risk of stroke, bleeding events, vascular access-site and access-related complications and immediate patient ambulation. It appears to be a valuable alternative access for patients who cannot undergo trans-femoral TAVI.

Video-assisted coronary bypass surgery : clinical results

OBJECTIVE Clinical experience with a video-assisted coronary artery bypass grafting procedure using the internal mammary artery is reported. The technique consists of a videoscopic harvesting of the left internal mammary artery (LIMA) to revascularise the left anterior descending artery (LAD) through a 4-cm left thoracotomy. METHODS Between September 1995 and July 1996, we performed this procedure on 30 patients (29 males, 1 female; aged 38-71) with an isolated proximal LAD stenosis (n = 21) or occlusion (n = 9). All patients were symptomatic despite appropriate medication. A history of non-transmural myocardial infarction with myocardial viability was found in nine patients. Fourteen patients had a restenosis after previous percutaneous transluminal coronary angioplasty (PTCA). Mean left ventricular ejection fraction was 0.61 (< 0.3 in two patients). The LAD LIMA anastomosis was performed on the beating heart without cardiopulmonary bypass (CPB) in 26 patients. Femoral-femoral CPB was used in three patients because of unstable angina (n = 1) and intramyocardial LAD (n = 2). Conversion to sternotomy and standard CPB was necessary in one patient for extensive endarterectomy of the LAD. RESULTS There were no operative complications and no reoperations for haemorrhage. Pulmonary infection was observed in one patient and wound infection in one patient. Patients who underwent the complete procedure on the beating heart without conversion or CPB were ready for discharge on the 5th postoperative day (36 h-13 days). Control coronary angiography was performed in 20 patients. In all cases, the graft was patent. In 17 cases, there was a patent graft with no evidence of anastomotic stenosis. An occlusion of the distal segment of the LAD with a retrograde perfusion of the proximal segment and septal branches by the LIMA was found in one case. This patient was symptom-free and the stress test was negative. An anastomotic stenosis was noted in two patients and was treated by angioplasty (n = 1) or conventional surgery (n = 1). CONCLUSION In conclusion, the efficiency of this minimally invasive approach should be prospectively compared with similar revascularisation with PTCA or surgical approaches using sternotomy with or without CPB.

Thoracoscopic IMA takedown.

Abstract  In recent years, the field of minimally invasive cardiac surgery has grown rapidly beginning with the MIDCAB operation and evolving toward totally endoscopic coronary artery bypass grafting (CABG). It promotes the goal of decreasing surgical trauma while maintaining surgical efficacy. For MIDCAB, a limited anterior thoracotomy or mediastotomy have been proposed to harvest the internal mammary artery (IMA). However, complete graft harvesting of the IMA is difficult under direct vision in these circumstances and may necessitate costal resection and important chest wall retraction. Additionally, it carries the potential risk of kinking or coronary steal syndrome.1–5 Thoracoscopic harvesting of the IMA avoids these hazards. It permits complete dissection from the subclavian artery to the sixth intercostal space (ICS) with section of all collateral branches issuing from the IMA without any traumatic retraction. The technique of IMA takedown described herein has been used regularly by us since 1995. Our current experience shows that it is safe and reproducible after a reasonable period of training. Furthermore, in the objective of performing a totally endoscopic and/or robotic CABG, thoracoscopic IMA takedown would be a prerequisite.

Long-term results of Freestyle stentless bioprosthesis in the aortic position: A single-center prospective cohort of 500 patients

OBJECTIVE Stentless xenograft bioprostheses may be the future valve of choice for aortic valve replacement. The study aim was to investigate the long-term clinical outcome after aortic valve replacement with the Medtronic Freestyle bioprosthesis (Medtronic Inc, Minneapolis, Minn). METHODS Between April 1997 and November 2004, a total of 500 patients (mean age, 74.5±9.6 years; 52% were male) underwent aortic valve replacement with a Freestyle bioprosthesis, without population selection. The surgical procedure used a modified subcoronary technique in 479 patients and a complete root replacement in 21 patients, conducted with mini-extracorporeal circulation. Concomitant procedures included coronary artery bypass grafting in 122 patients (24%) and mitral valve repair/replacement in 11 patients. RESULTS The mean cardiopulmonary bypass time was 98±26 minutes, and total aortic crossclamp time was 77±19 minutes. Operative mortality was 5.2%. The median follow-up time was 104.8±5.7 months. During this period, there were 224 deaths (n=122 cardiovascular and n=102 noncardiovascular deaths). The actuarial survivals from cardiovascular and valve-related mortality were 67%±3% and 70%±4%, respectively, at 10 years. Freedom from structural valve deterioration at 10 years was 94%±2%. The linearized structural valve deterioration incidence was 0.6% per patient/year. Multivariate Cox regression analysis revealed that older age, impaired renal function, and coronary artery disease were independent predictors of cardiovascular death. In the subgroup of patients aged less than 65 years at implantation (n=45), the actuarial cardiovascular survival was 83%±8% and freedom from structural valve deterioration was 89%±6% at 10 years. CONCLUSIONS The use of the Freestyle bioprosthesis for aortic valve replacement resulted in good long-term cardiovascular survival and freedom from structural valve deterioration in this cohort regardless of age at implantation.

Aortic Wrapping for Stanford Type A Acute Aortic Dissection: Short and Midterm Outcome

BACKGROUND Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. METHODS We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). RESULTS Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. CONCLUSIONS The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative.

Wrapping of the ascending aorta in acute type A retrograde aortic dissection.

We describe off-pump wrapping of the ascending aorta in 3 high-risk patients with acute type A aortic dissection when the primary intimal tear was not located in the ascending aorta and in the absence of aortic insufficiency. A Teflon plaque (Bard Inc, Murray Hill, NJ) was tailored to tightly wrap the aorta from the coronary ostia to the innominate artery. The mean age of the patients was 80.3 years. All patients were at high risk for conventional surgery. A postoperative computed tomographic scan showed a reapplication of the intimal flap and containment of the false lumen in the reinforced ascending aorta in all patients.

Retrocaval in situ RIMA for distal marginal arteries grafting

The length of the in situ right internal mammary artery (RIMA) often restricts its use as a graft to distal marginal arteries. We describe herein a retrocaval supra-azygous extra-pleural passage of the RIMA that allows a significant gain in length. We report our experience in 30 patients with distal marginal lesions or with large hearts.

Cardiac surgery combined with bypass from the ascending aorta to the bilateral femoral arteries for severe aorto-iliac occlusion: a case series

From the Departments of Cardiac surgery and Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital and University Paris-Sud, Le Plessis Robinson, France. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Sept 13, 2017; revisions received Nov 16, 2017; accepted for publication Nov 24, 2017; available ahead of print Jan 10, 2018. Address for reprints: Julien Guihaire, MD, PhD, Department of Cardiac Surgery, Marie Lannelongue Hospital, 133 Avenue de la R esistance, 92350 Le Plessis Robinson, France (E-mail: j.guihaire@ccml.fr). J Thorac Cardiovasc Surg 2018;155:1574-7 0022-5223/