Tomas A. Salerno

Partial Left Ventriculectomy to Treat End-Stage Heart Disease☆

BACKGROUNDnIt is reasoned that reducing left ventricular diameter (Laplaces law) in patients with dilated cardiomyopathy, will improve ventricular function.nnnMETHODSnPartial left ventriculectomy was performed in 120 patients with end-stage dilated cardiomyopathies of varying causes. Most patients were in New York Heart Association functional class IV. The procedure consisted of removal of a wedge of left ventricular muscle from the apex to the base of the heart. Depending on the distance between the two papillary muscles, the mitral valve apparatus was either preserved, repaired, or replaced with a tissue prosthesis.nnnRESULTSnThe 30-day mortality was 22% and the 2-year survival was 55%. Although 10% of surviving patients showed no improvement in New York Heart Association functional class, most of the surviving patients were in either class I (57%) or II (33.3%), and the others were in class III and IV.nnnCONCLUSIONSnPartial left ventriculectomy can be used to treat end-stage dilated cardiomyopathy. Further studies and a longer follow-up period are needed to fully assess the effects of this procedure.

Graft revision after transit time flow measurement in off-pump coronary artery bypass grafting

OBJECTIVEnTo determine whether coronary graft patency can be predicted by transit time flow measurement (TTFM).nnnMETHODSnFrom May 1 1997 to December 31 1998, TTFM was prospectively evaluated in 409 patients undergoing coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). All grafts (1145) were tested with TTFM.nnnRESULTSnThirty-seven out of 1145 grafts (3.2%) were revised in 33 patients (7.6%). In six cases (18.1%) use of CPB was necessary during revision due to hemodynamic instability. The remaining patients underwent revision off-pump. Thirty-four grafts (91.9%) were revised for both low flow and abnormal flow curve patterns. Findings at revision included: thrombosis of the anastomosis (n=6), stenosis at the toe or heel of the anastomosis (n=8), coronary flap or dissection (n=5), dissection of the internal mammary artery (n=5), graft kinking (n=4), flap at proximal anastomosis (n=1), coronary stenosis distal to the graft (n=3), and no findings (n=2). After revision all flow values and flow patterns improved. Although three additional grafts (8.1%) were revised for low flow (<7 ml/min) despite normal flow patterns, there were no findings at revision and flow values and curves remained unchanged after revision. Postoperatively, one patient developed a stroke (3%), one had an acute myocardial infarction (MI) (3%), one had a sternal wound infection (3%), and one required prolonged ventilatory support (3%).nnnCONCLUSIONnEvaluation of TTFM is valuable in determining the status of a coronary graft after CABG. Correct interpretation of flow patterns allows for correction of abnormalities prior to chest closure.

Minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting has recently been introduced into cardiac surgery. The procedure promises to become an important addition to the surgical treatment of coronary artery disease. This current review gives a historical perspective and an overview of this growing field, based on the experience of three international centers with experience with minimally invasive coronary artery bypass grafting. It is predicted that the field will grow, and that future generation of cardiac surgeons will have to become familiar with this new procedure.

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass

BACKGROUNDnMyocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians.nnnMETHODSnOf 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared.nnnRESULTSnThe groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant).nnnCONCLUSIONSnThis investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.

Blood product use in cardiac revascularization: comparison of on- and off-pump techniques.

BACKGROUNDnCardiac revascularization on a beating heart avoids the side effects of cardiopulmonary bypass (eg, neurologic injury, hemodilution, and coagulopathy). We examined perioperative bleeding and use of blood products during coronary artery bypass grafting using either on-pump or off-pump techniques.nnnMETHODnThe charts of 126 patients who had coronary artery bypass grafting were reviewed. Data from 66 patients revascularized off pump and 60 patients with cardiopulmonary bypass (on pump) were analyzed using unpaired Students t test.nnnRESULTSnAverage age was 62.5 years in either group. More patients received heparin preoperatively in the off-pump group that resulted in mild elevation of preoperative partial thromboplastin time and activated clotting time (40.4 +/- 2.9 seconds and 150.1 +/- 5.3 seconds, respectively). However, the off-pump group had less perioperative (intraoperative or postoperative) bleeding (2312 +/- 212 mL versus 3251 +/- 155 mL, p < 0.05) and required fewer blood products compared with the on-pump group. Hemoglobin and platelets decreased more in the conventional on-pump group.nnnCONCLUSIONSnAvoiding cardiopulmonary bypass decreases perioperative bleeding and, consequently, reduces the use of blood products after coronary artery bypass grafting, which might result in fewer transfusion-related complications.

“Single suture” for circumflex exposure in off-pump coronary artery bypass grafting

Exposure of coronary vessels in the circumflex territory for surgery off cardiopulmonary bypass (CPB) is a challenge. Ricardo Lima from Brazil described a series of sutures that enable surgeons to expose the marginal circumflex vessels on the beating heart. We have modified this technique and only use a single suture placed in the oblique sinus of the posterior pericardium. This allows for successful exposure of all coronary vessels with minimal manipulation of the heart. This simple technique enhances surgery on the beating heart and is especially useful to bypass topographically difficult posterior and lateral coronary vessels.

Conversion to Cardiopulmonary Bypass in Off-pump Coronary Artery Bypass Grafting: Its Effect on Outcome

Abstract The surgical outcome of patients requiring conversion to cardiopulmonary bypass (CPB) during myocardial revascularization using the less invasive surgical approach (LISA) was assessed. The LISA was recently introduced as a technique for complete myocardial revascularization without CPB. It combines avoidance of CPB with the versatility of a median sternotomy for access to all coronary vessels. We have previously demonstrated reduced risk‐adjusted mortality and complications in off‐CPB coronary artery bypass grafting (CABG) using LISA compared to standard myocardial revascularization. From January to December 1997, 1210 patients underwent isolated CABG at our institution. Of these patients, 832 (63%) were scheduled as on‐CPB cases and 378 (37%) as off‐CPB. Of the off‐CPB patients, 48 were converted to CPB. Team A surgeons used LISA as their primary strategy for CABG whereas team B surgeons used off‐CPB CABG in selected patients. Conversions were divided in three classes: Class I patients were converted when the surgeon considered complete revascularization impossible off‐CPB; Class II patients were converted due to hemodynamic instability during the procedure; and Class III patients were converted due to graft malfunction, determined by flow measurements or clinical evidence. There were four deaths. All had perioperative infarctions and required intra‐aortic balloon pump (IABP). Conversion to CPB occurred in up to 25% of patients scheduled for off‐CPB CABG. When off‐CPB cases are done using the comprehensive LISA technique and modern technology, conversion rates may be reduced to 11%. Conversion is in general well tolerated except when it is instituted for graft malfunction combined with hemodynamic instability or collapse.

Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery

OBJECTIVEnThe purpose of this study was to evaluate morbidity and mortality in reoperative coronary artery bypass surgery using the New York State database.nnnMETHODSnPatients undergoing reoperative coronary artery bypass between January-1995 and December 1996 were included. Patients were operated using cardiopulmonary bypass (CPB group, n = 184) or without cardiopulmonary bypass (non-CPB group, n = 105) by surgeon preference. Groups were compared for preoperative risk factors, postoperative mortality and major complications.nnnRESULTSnCrude mortality was lower in the non-CPB group, despite a higher expected mortality, resulting in a risk-adjusted mortality of 1.3% versus 2.7% for the CPB group (NS). Of non-CPB patients, 91.4% were without complications, while only 72.1% of CPB patients (P < 0.0001) were complication-free. Major complications were significantly reduced in non-CPB patients compared to CPB patients: stroke 0% versus 3.8% (P < 0.04), cardiovascular complications 4.8% versus 15.8% (P < 0.005), other major complications 1.9% versus 10.4% (P < 0.007). Postoperative IABP support was needed in 1.9% of the non-CPB group patients and in 14.2% of the CPB group (P < 0.0007).nnnCONCLUSIONSnThe main object of reoperative CABG is to relieve symptoms, since the survival benefit of the procedure has not been demonstrated. Performance of reoperative coronary artery bypass surgery without cardiopulmonary bypass significantly reduces morbidity. We conclude that cardiopulmonary bypass should be avoided whenever possible in reoperative coronary bypass surgery.

Survey of resident training in beating heart operations

BACKGROUNDnOff-pump coronary artery operations are done with increasing frequency in the treatment of coronary artery disease. As a result, residents in thoracic surgery have been confronted with the necessity of gaining experience in this innovative approach to coronary surgery. The aim of this study was to assess the importance of training in minimally invasive coronary revascularization as it was perceived by thoracic surgery residents.nnnMETHODSnA postal, multiple-choice survey questionnaire was sent to all cardiothoracic surgery residents (n = 327) of accredited training programs in the United States. Responses were tabulated and analyzed.nnnRESULTSnThe overall response rate was 68% (222 of 327 residents). The attending staff was very interested (37%), or had some interest (63%), in beating heart coronary revascularization. Ninety-eight percent of the programs had at least one surgeon performing off-pump procedures. Although 88% of the responding residents showed some interest in off-pump coronary operations, only 22% of them had performed more than 20 off-pump cases, and even less (12%) had performed more than 20 cases of off-pump complete revascularization, or off-pump circumflex revascularization (4%). Sixteen percent of them had no clinical experience with these techniques. Regarding career intentions, 88% of the residents indicated that off-pump coronary operations were expected to be part of the practice, and 58% of them were interested in pursuing additional training in less invasive heart procedures.nnnCONCLUSIONSnThe results of this survey suggest that training in off-pump coronary revascularization is variable across training programs, and that the majority of residents may not reach proficiency in coronary procedures on the beating heart during their residency. This may adversely affect their future expectations, as 88% of them would like to practice off-pump coronary surgery once the training is completed.

Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta.

Endovascular stent graft repair of descending thoracic aortic aneurysms has been recently introduced as an alternative to conventional graft replacement of the diseased aorta. As experience with this new technique accumulates, complications may occur. We herein report the case of a patient in whom we observed distal migration with leak of an endovascular stent graft previously inserted in the descending thoracic aorta, associated with an aortobronchial fistula. The urgent surgical treatment undertaken, which consisted of graft replacement of the previously stented aorta, had a fatal outcome.