Sacha P. Salzberg

Mitral Valve Repair With Carpentier-McCarthy-Adams IMR ETlogix Annuloplasty Ring for Ischemic Mitral Regurgitation Early Echocardiographic Results From a Multi-Center Study

Background— Ischemic mitral regurgitation (IMR) is associated with asymmetric changes in annular and ventricular geometry. Surgical repair with standard symmetric annuloplasty rings results in a high incidence of residual or recurrent mitral regurgitation (MR). The Carpentier-McCarthy-Adams (CMA) IMR ETlogix annuloplasty ring is the first remodeling ring specifically designed to treat asymmetric leaflet tethering and annular dilatation. We used quantitative 2-dimensional echo to examine early results of mitral valve (MV) repair with the CMA IMR ETlogix annuloplasty ring in patients with IMR. Methods and Results— Fifty-nine patients (aged 68±12 years) with grade ≥2+ IMR (graded on a scale of 0 to 4+) underwent MV repair with the CMA IMR ETlogix annuloplasty ring. We assessed the mitral annular diameter (MAD), tethering area (TA), and tenting height (TH) of the MV in 4-chamber, 2-chamber, and long axis views at mid-systole before and 3 to 10 days after surgery. After surgery, 57 of 59 (97%) patients had grade 0 or 1+ MR, whereas 2 patients had 2+ MR. MV repair with the CMA IMR ETlogix ring significantly reduced MAD, TA, and TH (P<0.001, for all 3 echo views), particularly in the long axis and 4-chamber views. Conclusion— Surgical repair of IMR with the novel asymmetric CMA IMR ETlogix annuloplasty ring provided excellent early results with effective reduction of MR, MAD, and leaflet tethering. This novel etiology-specific strategy may result in improved outcomes in IMR patients.

Left atrial appendage clip occlusion: Early clinical results

OBJECTIVE Atrial fibrillation puts patients at significant risk for embolic stroke originating from the left atrial appendage. Few means are available for safe, effective, and durable left atrial appendage occlusion. A new clip device was evaluated with regard to safety and effectiveness for epicardial left atrial appendage occlusion. METHODS Patients with atrial fibrillation undergoing elective cardiac surgery through a median sternotomy were enrolled for concomitant epicardial clip placement. Early postoperative and 3-month follow-up computed tomography studies were used to assess clip stability and left atrial appendage perfusion. RESULTS From September 2007 to December 2008, 34 patients underwent successful clip placement. No device-related complications occurred. Operative mortality was 8.8% and not study or device related. Deployment was rapid, and left atrial appendage occlusion was confirmed by intraoperative transesophageal echocardiography in all patients. In addition to excellent clinical outcomes (no stroke/transient ischemic attack), serial computed tomography demonstrated stable clip location and appendage perfusion at 3 months in all patients. CONCLUSION Safe, effective, and durable left atrial appendage occlusion can easily be achieved with this new clip. Further trials are necessary to evaluate the role of the left atrial appendage occlusion in stroke prevention.

Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multivessel disease?

OBJECTIVE Diabetic patients often present with diffuse coronary disease than nondiabetic patients posing a greater surgical challenge during off-pump revascularization. In this study, the safety, feasibility, and completeness of revascularization for this subset of patients was assessed. METHODS From 2002 to 2008, 1015 diabetic patients underwent myocardial revascularization. Patients received either off-pump coronary artery bypass (OPCAB; n = 540; 53%) or coronary artery bypass grafting (CABG; n = 475; 47%). Data collection was performed prospectively and data analysis was done by propensity-score (PS)-adjusted regression analysis. Primary endpoints were mortality, major adverse cardiac and cerebrovascular events (MACCEs), and a composite endpoint including major noncardiac adverse events (MNCAEs) such as respiratory failure, renal failure, and rethoracotomy for bleeding was applied. An index of complete revascularization (ICOR) was defined to assess complete revascularization by dividing the total number of distal anastomoses by the number of diseased vessels. Complete revascularization was assumed when ICOR was >1. RESULTS OPCAB patients had a significantly lower mortality-rate (1.1% vs 3.8%; propensity-adjusted odds ratio (PAOR) = 0.11; p = 0.018) and displayed less frequent MACCE (8.3% vs 17.9%; PAOR = 0.66; p = 0.07) including myocardial infarction (1.3% vs 3.2%; PAOR = 0.33; p = 0.06) and stroke (0.7% vs 2.3%; PAOR = 0.28; p = 0.13). Similarly, a significantly lower occurrence of the noncardiac composite endpoint (MNCAE) (PAOR = 0.46; confidence interval (CI) 95% 0.35-0.91; p < 0.001) was detected. In particular, lesser respiratory failure (0.9% vs 4.3%; PAOR = 0.24; p = 0.63) and pleural effusions (3.3% vs 7.5%; PAOR = 0.45; p = 0.04) occurred, so that fast extubation (≤ 12 h postoperative) was more frequently possible (58.3% vs 34.2%; PAOR = 1.64; p = 0.007). The number of arterial grafts was significantly higher among OPCAB patients (1.54 ± 0.89 vs 1.33 ± 0.81; p = 0.006) due to a more frequent use of the right-internal mammary artery (35.6% vs 22.9%; p < 0.001). ICOR was significantly higher among CABG patients (1.24 ± 0.34 vs 1.30 ± 0.28; p = 0.001). However, for similar proportions in both groups, an ICOR > 1 was achieved clearly indicating complete revascularization (94.3% vs 93.7%; p = 0.24). CONCLUSIONS OPCAB offers a lower mortality and superior postoperative outcomes in diabetic patients with multivessel disease. Arterial grafts are used more frequently that may contribute to better long-term outcomes and the OPCAB approach does not come at the cost of less complete revascularization.

How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery

OBJECTIVES The refusal of blood products makes open-heart surgery in Jehovahs witnesses (JW) an ethical challenge. We demonstrate how patient blood management strategies lead to excellent surgical outcomes. METHODS From 2003 to 2008, 16 JW underwent cardiac surgery at our institution. Only senior surgeons performed coronary revascularization (n=6), valve (n=6), combined (n=1) and aortic surgery (n=3) of which two patients presented with acute type-A dissection. Off-pump surgery remained the method of choice for patients requiring a bypass procedure (n=5). Preoperative hematocrit (Hk) and hemoglobin (Hb) were 42.8±4.7% and 14.5±2 g/dl. In three patients with an Hb<12 g/dl, preoperative hematological stimulating treatment was implemented. RESULTS All patients survived, no major complications occurred and no blood transfusion was administered. The Cell Saver® system (transfused volume: 474±101 ml) and synthetic plasma substitutes [Ringers Lactate: 873±367 ml and hydroxyethyl starch (HES) 6%: 700±388 ml] were used routinely as well as hemostaticas, such as bone wax, and fibrin glue. The decrease of Hk and Hb appeared to be the lowest after off-pump surgery when compared to all other procedures requiring cardiopulmonary bypass (CPB) (25±9% vs. 33±6%; P=0.01 and 22±9% vs. 31±6%; P=0.04). Similarly, the decrease of platelets was significantly lower (20±12% vs. 43±14%; P=0.01). In the follow-up period (52±34 months), one patient died due to a non-cardiac reason, whereas all others were alive, in good clinical condition and did not have major adverse cardiac events (MACE) or recurrent symptoms requiring re-intervention. CONCLUSION Patient blood management leads to excellent short- and long-term outcomes in JW. Combined efforts in regard to preoperative hematological parameter optimization, effective volume management and meticulous surgical techniques make this possible but raise the cautionary note why this is only possible in JW patients.

Epicardial left atrial appendage clip occlusion also provides the electrical isolation of the left atrial appendage.

OBJECTIVES The exclusion of the left atrial appendage (LAA) has been used to reduce the risk of stroke associated with atrial fibrillation (AF). While LAA exclusion has been associated with a reduced risk of stroke, the effect on the electrical activity of the LAA (a potential source of AF) remains unknown. As such, we sought to demonstrate whether surgical epicardial clip occlusion leads to the electrical isolation of the LAA. METHODS From December 2010 until August 2011, 10 patients with paroxysmal AF underwent off-pump coronary artery bypass surgery with bilateral pulmonary vein isolation and an LAA clip occlusion with a new epicardial clip. Before and after the clip was placed, pacing manoeuvres were performed to assess the electrical exit and entry blocks from the LAA. RESULTS All clips were applied successfully. The mean procedure time for the clip application was 4 ± 1 min. No complications occurred related to clip application. Prior to the pericardial closure, 18 ± 3 min after the clip placement, the LAA stimulation and pacing manoeuvres demonstrated complete electrical isolation of the LAA in all cases. CONCLUSIONS Epicardial LAA clip occlusion leads to the acute electrical isolation of the LAA and may not only provide stroke prevention but also reduce the recurrence of AF.

Cardiac CT and echocardiographic evaluation of peri-device flow after percutaneous left atrial appendage closure using the AMPLATZER cardiac plug device

The aim of the study was to examine frequency, size, and localization of peri‐device leaks after percutaneous left atrial appendage (LAA)‐closure with the AMPLATZER‐Cardiac‐Plug (ACP) by using a multimodal imaging approach, i.e. combined cardiac‐CT and TEE follow‐up.

Routine Off-Pump Coronary Artery Bypass Grafting Is Safe and Feasible in High-Risk Patients With Left Main Disease

BACKGROUND Coronary artery bypass graft surgery (CABG) remains the method of choice for patients with left main disease (LMD). The precise role of off-pump coronary artery bypass graft surgery (OPCABG) remains unclear in this setting. We report the safety and feasibility of a routine OPCABG approach to patients with LMD. METHODS From 2002 to 2007, 983 patients underwent myocardial revascularization at our institution. We compared 343 OPCABG patients with LMD (group A) to 640 OPCABG patients without LMD (group B). The relationship between the presence of LMD and outcome in OPCABG procedures was statistically assessed. A composite endpoint (30-day mortality, postoperative renal failure, intensive care unit length of stay [>2 days], neurologic complications, use of intra-aortic balloon pump, and conversion to cardiopulmonary bypass) was also used. In addition, completeness of revascularization was compared in both groups. RESULTS Group A had a lower mortality rate (1.7% versus 2.2%; p=0.81), and no differences were noted in conversion to cardiopulmonary bypass (6.7% versus 5.3%; p=0.39), intra-aortic balloon pump use (0.3% versus 1.4%; p=0.18), and occurrence of composite endpoint (30.9% versus 30.8%; p=0.99). The number of arterial grafts per patient was significantly higher among patients in group A (1.77+/-0.95 versus 1.66+/-0.95; p=0.029) owing to the more frequent use of the right internal mammary artery (49.6% versus 42.3%; p=0.031), whereas the total number of distal anastomoses (3.72+/-0.90 versus 3.62+/-1.01; p=0.28) and complete revascularization (94% versus 95%; p=0.55) were similar. Logistic regression confirmed that LMD is no risk factor for the occurrence of our composite endpoint (odds ratio 1.00; 95% confidence interval: 0.75 to 1.33; p=0.99). CONCLUSIONS A modern OPCABG approach offers low mortality, excellent clinical outcomes, and does not come at the price of less complete revascularization in these high-risk patients.

Increased Neointimal Formation After Surgical Vein Grafting in a Murine Model of Type 2 Diabetes

Background— Diabetes is an independent risk factor for the development of neointimal hyperplasia and subsequent vein graft failure after coronary or peripheral artery bypass grafting. We evaluate a new mouse model of surgical vein grafting to investigate the mechanisms of neointimal formation in the setting of type 2 diabetes. Methods and Results— Surgical vein grafts were created by inserting vein segments from age-matched C57BL/KsJ wild-type mice into the infra-renal aorta of leprdb/db diabetic and C57BL/KsJ wild-type mice. Mice were euthanized ≈4 weeks later, and vein grafts were analyzed using morphometric and immunohistochemical techniques. A significant increase in neointimal formation was noted in leprdb/db mice (139±64 versus 109±62 mm2; P=0.008) after 4 weeks. This difference was mainly secondary to an increase in collagen formation within the lesion in the vein grafts from leprdb/db mice (0.53±0.4 versus 0.44±0.05; P<0.001), whereas only slight increases (P=not significant) in alpha actin-stained smooth muscle cells were noted in the leprdb/db mice. Conclusion— We established a new physiologically relevant model of surgical vein grafting in mice. In this report, type 2 diabetes was associated with significant increase in extracellular matrix deposition in addition to increased smooth muscle cell deposition. This new model may allow mechanistic studies of cellular and molecular pathways of increased neointimal formation in the setting of diabetes.

Transvenous lead extractions: comparison of laser vs. mechanical approach.

AIMS In this retrospective study we compared different lead extraction techniques. METHODS AND RESULTS Between January 2009 and December 2012 we performed transvenous lead extraction procedures on 206 leads in 122 patients. Mean implant duration (MID) was 69.6 months (1-384 months). Leads with lead implant duration ≥ 12 months were assigned to groups according to the extraction technique: Group A: no extraction tool; Group B: laser approach; and Group C: mechanical approach. Overall clinical success was 93.3%. Group A showed a significantly lower MID [38.1 (19-122) months] compared with Groups B and C [83.1 (13-168) months; P < 0.0001 vs. 95.4 (12-384) months; P < 0.0001]. Mean implant duration between Groups B and C did not differ significantly (P = 0.28). Clinical and complete procedural success was 100% in Group A. Clinical success rate was higher in Group C than in Group B (97.0 vs. 76.9%, P = 0.018). Complete procedural success did not differ significantly between Groups B and C (88.9 vs. 76.9%; P = 0.132). In Groups B and C, absence of complete procedural success occurred in long implanted leads (MID 107.8 ± 36.4 and 137.6 ± 89.2 months). Relative costs per extracted lead were 49% higher in Group B than in Group C. CONCLUSION In case of long implanted leads a laser and a mechanical approach are comparable in complete procedural success and safety. Clinical success and cost effectiveness analysis favours the mechanical approach. Regardless of the extraction technique efficacy and safety optimization has to focus on long implanted leads.

Coronary artery surgery: conventional coronary artery bypass grafting versus off-pump coronary artery bypass grafting.

Purpose of review Coronary revascularization has become the principal treatment modality in patients with severe coronary artery disease. The broader application of percutaneous coronary interventions in patients with multivessel disease and the recent introduction of drug-eluting stents have both lead to a decline in the number of patients referred for surgical revascularization. Conventional coronary artery bypass grafting using cardiopulmonary bypass is an excellent treatment, however less invasive surgical approaches such as off-pump coronary artery bypass grafting have appeared in the past few years. The exact role of off-pump coronary artery bypass grafting is still vaguely defined and being critically evaluated. Our aim is to provide an objective review of the recent literature in regard to surgical outcomes. Recent findings A critical review of all relevant clinical series from May 2003 to May 2005 was conducted. Current prospective data suggests that both techniques have similar rates of mortality, in regard to morbidity, multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. The incidence of postoperative myocardial infarction does not appear to differ between techniques. When analyzed carefully, the results presented herein seem to indicate that both techniques provide similar rates for long-term patency and freedom from surgical reintervention. Summary Coronary artery bypass grafting and off-pump coronary artery bypass grafting are both safe and beneficial in patients with multivessel coronary artery disease. It appears that elderly patients with additional co-morbid risk factors may benefit most from off-pump coronary artery bypass grafting. It has become increasingly apparent that off-pump coronary artery bypass grafting can be performed safely in reference centers.