Willem J.L. Suyker

Randomized Comparison Between Stenting and Off-Pump Bypass Surgery in Patients Referred for Angioplasty

Background—Stenting improves cardiac outcome in comparison with balloon angioplasty. Compared with conventional surgery, off-pump bypass surgery on the beating heart without cardiopulmonary bypass may reduce morbidity, hospital stay, and costs. The purpose, therefore, was to compare cardiac outcome, quality of life, and cost-effectiveness 1 year after stenting and after off-pump surgery. Methods and Results—Patients referred for angioplasty (n=280) were randomly assigned to stenting (n=138) or off-pump bypass surgery. At 1 year, survival free from stroke, myocardial infarction, and repeat revascularization was 85.5% after stenting and 91.5% after off-pump surgery (relative risk, 0.93; 95% CI, 0.86 to 1.02). Freedom from angina was 78.3% after stenting and 87.0% after off-pump surgery (P =0.06). Quality-adjusted lifetime was 0.82 year after stenting and 0.79 year after off-pump surgery (P =0.09). Hospital stay after the initial procedure was 1.43 and 5.77 days, respectively (P <0.01). Stenting reduced overall costs by

Role of Coronary Collaterals in Off-Pump and On-Pump Coronary Bypass Surgery

2933 (26.2%) per patient (

OFF-PUMP CORONARY ARTERY BYPASS SURGERY

8276 versus

Coronary Connector Devices: Analysis of 1,469 Anastomoses in 1,216 Patients

11 209; P <0.01). Stenting was more cost-effective in 95% of the bootstrap estimates. Conclusions—At 1 year, stenting was more cost-effective than off-pump surgery while maintaining comparable cardiac outcome and quality of life. Stenting rather than off-pump surgery, therefore, can be recommended as a first-choice revascularization strategy in selected patients.

Risk factors and prognosis of postpericardiotomy syndrome in patients undergoing valve surgery

Background—Collaterals limit infarct size, preserve viability, and reduce mortality in patients with acute myocardial infarction. In patients with stable coronary disease, collaterals are associated with less angina and ischemia during angioplasty and fewer ischemic events during follow-up. The role of collaterals has not been studied in patients undergoing off-pump or on-pump bypass surgery. Methods and Results—The population consisted of the 281 patients randomized to off-pump or on-pump CABG in the Octopus Study. Collaterals were defined on the baseline angiogram with the Rentrop score and were present in 49% and 51% of the patients in the off-pump and on-pump group, respectively. Perioperative myocardial infarction was defined by a creatine kinase-MB to CK ratio >10% and occurred in 18.2% in the off-pump group and 32.5% in the on-pump group. The unadjusted OR of perioperative myocardial infarction in the presence of collaterals was 0.31 (95% CI 0.17 to 0.84) in the off-pump group and 1.06 (95% CI 0.29 to 3.85) in the on-pump group After adjustment for age, gender, hypertension, hypercholesterolemia, diabetes, multivessel disease, ventricular dysfunction, incomplete revascularization, and ischemic time, the OR was 0.34 (95% CI 0.14 to 0.84) in the off-pump group and 1.28 (95% CI 0.30 to 5.40) in the on-pump group, respectively. Kaplan-Meier estimates of event-free survival at 1 year were 87% in patients with and 69% in those without collaterals after off-pump CABG. These estimates were 66% and 63%, respectively, after on-pump CABG. Conclusions—Collaterals protect against perioperative myocardial infarction during off-pump surgery but not during on-pump surgery and are associated with a better 1-year event-free survival.

Aortic homograft replacement in a patient with a porcelain aorta: A case report

Coronary revascularisation plays an important role in the management of patients with ischaemic heart disease. Its principle builds on restoring antegrade flow thereby relieving angina. As a result, the need for medication is reduced which, in turn, may improve quality of life and socioeconomic independency. Also the prognosis is beneficially affected. This is not only true for patients with severe coronary atherosclerosis such as patients with left main or three vessel disease, but also for patients with less advanced disease.w1–3 The first milestones in coronary revascularisation were surgical. It all started after the second world war with the implantation of the internal mammary artery indirectly into the cardiac muscle (the Vineberg procedure). A few years later, procedures for direct coronary artery revascularisation were designed, initially including endarterectomy, followed by the construction of an anastomosis between a donor artery or vein and the coronary artery. Interestingly, these first operations were performed on the beating heart without the use of extracorporeal circulation and cardiac arrest.w4 The results of these early initiatives were generally unpredictable, preventing general acceptance and widespread use. It became clear that the safety and efficacy of surgical coronary revascularisation in terms of in-hospital complications and immediate and long term clinical outcome greatly depends, among other factors, on the quality of the anastomosis between the donor graft and recipient coronary artery. To predictably create these delicate and very precise hand sewn anastomoses, the surgeon needs a still and bloodless field with full exposure of the target area, enabling the required complex and coordinated manipulation of the microsurgical instruments. In this respect, the introduction of cardiopulmonary bypass (CPB) and cardiac arrest by Favaloro in 1967 proved to be a tremendous step forward. Because basic surgical requirements could now be properly addressed, consistent high quality anastomoses could be produced …

Functional connectivity and network analysis during hypoactive delirium and recovery from anesthesia

Automated coronary anastomotic devices could be the key to limited or port access procedures. To evaluate their clinical performance to date, 33 studies that included systematic elective angiographic imaging were reviewed, reporting on five proximal and seven distal devices. Marked outcome differences between the technologies were uncorrelated to study type and demographic, operative, and follow-up variables. Significant issues included graft thrombosis, graft kinking, and stenosing intimal hyperplasia inside the connector, limiting clinical applicability of at least three devices. Substantial equivalence to 1-year conventional anastomotic patency standards was found for selected anastomotic devices, which holds the promise of expanded applicability.

Frequency of abnormal findings on routine chest radiography before cardiac surgery

Objective: The study aim was to investigate the long‐term prognosis and risk factors of postpericardiotomy syndrome (PPS). Methods: We performed a single‐center cohort study in 822 patients undergoing nonemergent valve surgery. Risk factors of PPS were evaluated using multivariable logistic regression analysis. We also compared the incidence of reoperation for tamponade at 1 year between patients with and without PPS. Main secondary outcomes were hospital stay and mortality. Results: Of the 822 patients, 119 (14.5%) developed PPS. A higher body mass index (odds ratio (OR) per point increase, 0.94; 95% confidence interval (CI), 0.89–0.99) was associated with a lower risk of PPS, whereas preoperative treatment for pulmonary disease without corticosteroids (OR, 2.55; 95% CI, 1.25–5.20) was associated with a higher risk of PPS. The incidence of reoperation for tamponade at 1 year in PPS versus no PPS was 20.9% versus 2.5% (OR, 15.49; 95% CI, 7.14–33.58). One‐year mortality in PPS versus no PPS was 4.2% versus 5.5% (OR, 0.68; 95% CI, 0.22–2.08). Median hospital stay was 13 days (interquartile range, 9–18 days) versus 11 days (interquartile range, 8–15 days) (P = .001), respectively. Conclusions: Despite longer hospital stays and more short‐term reoperations for tamponade, patients with PPS had an excellent 1‐year prognosis.

S2 Connector Versus Suture Distal Coronary Anastomosis Remodeling, Patency, and Function in the Pig

Patients with a severely calcified (porcelain) aorta are often unsuitable candidates for cardiac surgery because of the high risk of neuroembolic complications from loose calcified particles.We describe a surgical technique in a patient with a porcelain aorta undergoing an aortic homograft replacement for infective endocarditis that used an oscillating saw and a surgical hand drill for suturing the calcified plates.

White blood cell count and new-onset atrial fibrillation after cardiac surgery

OBJECTIVE To gain insight in the underlying mechanism of reduced levels of consciousness due to hypoactive delirium versus recovery from anesthesia, we studied functional connectivity and network topology using electroencephalography (EEG). METHODS EEG recordings were performed in age and sex-matched patients with hypoactive delirium (n=18), patients recovering from anesthesia (n=20), and non-delirious control patients (n=20), all after cardiac surgery. Functional and directed connectivity were studied with phase lag index and directed phase transfer entropy. Network topology was characterized using the minimum spanning tree (MST). A random forest classifier was calculated based on all measures to obtain discriminative ability between the three groups. RESULTS Non-delirious control subjects showed a back-to-front information flow, which was lost during hypoactive delirium (p=0.01) and recovery from anesthesia (p<0.01). The recovery from anesthesia group had more integrated network in the delta band compared to non-delirious controls. In contrast, hypoactive delirium showed a less integrated network in the alpha band. High accuracy for discrimination between hypoactive delirious patients and controls (86%) and recovery from anesthesia and controls (95%) were found. Accuracy for discrimination between hypoactive delirium and recovery from anesthesia was 73%. CONCLUSION Loss of functional and directed connectivity were observed in both hypoactive delirium and recovery from anesthesia, which might be related to the reduced level of consciousness in both states. These states could be distinguished in topology, which was a less integrated network during hypoactive delirium. SIGNIFICANCE Functional and directed connectivity are similarly disturbed during a reduced level of consciousness due to hypoactive delirium and sedatives, however topology was differently affected.