Yasser Y. Hegazy

Short term outcomes of total arterial coronary revascularization in patients above 65 years: a propensity score analysis

BackgroundDespite the advantages of bilateral mammary coronary revascularization, many surgeons are still restricting this technique to the young patients. The objective of this study is to demonstrate the safety and potential advantages of bilateral mammary coronary revascularization in patients older than 65 years.MethodsGroup I included 415 patients older than 65 years with exclusively bilateral mammary revascularization. Using a propensity score we selected 389 patients (group II) in whom coronary bypass operations were performed using the left internal mammary artery and the great saphenous vein.ResultsThe incidence of postoperative stroke was higher in group II (1.5% vs. 0%, P = 0.0111). The amount of postoperative blood loss was higher in group I (908 ± 757 ml vs. 800 ± 713 ml, P = 0.0405). There were no other postoperative differences between both groups.ConclusionBilateral internal mammary artery revascularization can be safely performed in patients older than 65 years. T-graft configuration without aortic anastomosis is particularly beneficial in this age group since it avoids aortic manipulation, which is an important risk factor for postoperative stroke.

The Use of Bilateral Internal Mammary Artery Grafting in Different Degrees of Obesity.

Background Obesity is a limiting factor for the use of bilateral internal mammary arteries (BIMAs). Therefore, we assessed the safety of their use in different degrees of obesity. Patients and Methods We studied two groups of patients with obesity using propensity matching. The first group received single internal mammary artery and saphenous vein grafts (SIMA group, 526 patients) and the second group received bilateral internal mammary arteries (BIMA group, 526 patients). Patients were classified further according to their body mass index (BMI) into overweight (BMI = 25‐29.9 kg/m2), obese (BMI = 30‐34.9 kg/m2), and severely obese (BMI ≥ 35 kg/m2). Results Preoperative data were similar regarding age (62.78 ± 9.96 vs. 62.98 ± 9.66 years; p = 0.734), female sex (17.5 vs. 18.6%; p = 0.631), diabetes mellitus (26.3 vs. 27.2%; p = 0.74), EuroSCORE (3.21 ± 2.23 vs. 3.18 ± 2.41; p = 0.968), and COPD (16 vs. 16%; p = 1). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.09 ± 0.84 vs. 3.12 ± 0.83; p = 0.633), myocardial infarction (1.7 vs. 1.7%; p = 1), reexploration (1.3 vs. 2.1%; p = 0.34), deep sternal wound infection (DSWI) (2.1 vs. 2.9%; p = 0.43), and 30‐day mortality (0.8 vs. 1.1%; p = 0.53). Multivariate analysis identified BMI and intensive care unit stay as independent predictors for DSWI. However, postoperative blood loss (694.56 ± 631.84 vs. 811.67 ± 688.73 mL; p < 0.001) and the incidence of pneumothorax (1 vs. 2.7%; p = 0.037) were higher in BIMA group. Conclusion Patients with obesity can benefit from BIMA grafting. However, postoperative blood loss and the incidence of pneumothorax can be higher using this technique.

Implementation of the aortic no-touch technique to reduce stroke after off-pump coronary surgery

Objectives Despite substantial scientific effort, the relationship between stroke after coronary artery bypass grafting and the use of the aortic no‐touch off‐pump technique (anOPCAB) remains incompletely understood. The present study aimed to define the effect of anOPCAB on the occurrence and time point of stroke. Methods A total cohort of 15,042 consecutive patients underwent surgical myocardial revascularization at a single institution. After establishing anOPCAB as routine procedure, 4695 patients received surgery by 18 different surgeons using the anaortic approach. After the exclusion of all patients with cardiogenic shock and “side‐clamp” off‐pump coronary artery bypass grafting, 13,279 patients (4485 with anOPCAB) were included in the study. Perioperative strokes were classified as strokes occurring during the hospital stay, with early strokes observed immediately after emergence from anesthesia (vs delayed strokes). Results The anOPCAB technique reduced the postoperative stroke rate to 0.49% versus 1.31% in on‐pump patients (P < .0001). The overall stroke rate after adoption of anOPCAB (0.64%) decreased compared with before its adoption (1.40%; P < .0001). With anOPCAB, the risk of early strokes virtually disappeared to 4 of 4485 patients (0.09%; 95% confidence interval, 0.00‐0.18% vs 0.83% in on‐pump patients; P < .0001), whereas the incidence of delayed strokes was not affected (0.40% vs 0.48%; P = .5181). The key results were confirmed after adjustment using propensity score–based analyses. Conclusions The anOPCAB technique with avoidance of any aortic manipulation is an effective tool to minimize the risk of early strokes during coronary artery bypass grafting, and thus, should be considered as a routine approach. In contrast, additional preventive strategies against delayed strokes remain to be elaborated.

Medtronic Freestyle aortic bioprosthesis: a potential option for haemodialysis patients †

OBJECTIVES End-stage renal disease patients on regular haemodialysis are at higher risk of calcification. Therefore, many surgeons have concerns regarding the implantation of bioprostheses in such patients. The haemodynamic advantages of stentless aortic bioprostheses support their use; however, these have not been studied yet in end-stage renal disease patients. We studied accordingly the early and mid-term outcomes of aortic valve replacement (AVR) using Medtronic Freestyle stentless aortic bioprostheses in this subset of patients in comparison with stented aortic bioprostheses. METHODS We retrospectively studied two groups of consecutive patients on regular haemodialysis who required AVR between 2007 and 2013. Non-Freestyle (NFS) group received stented aortic bioprostheses (36 patients) and Freestyle (FS) group received Medtronic Freestyle aortic bioprostheses (48 patients). Follow-up ranged from 2 to 76 months with a mean follow-up of 36.3 ± 25 months. RESULTS Patients in both groups showed similar demographic characters regarding age (76.4 ± 8.1 vs 74.9 ± 7.2 years; P = 0.35), male gender (58 vs 60%; P = 0.57) and diabetes mellitus (42 vs 48%; P = 0.57). Smaller aortic bioprostheses were implanted in the NFS (23.3 ± 1.2 vs 25.4 ± 2.1; P < 0.001) with consequently higher postoperative mean gradients (14.1 ± 4.1 vs 11.9 ± 5.3 mmHg; P = 0.004). No significant differences were noted regarding postoperative neurological disorder (8 vs 12%; P = 0.73), deep sternal wound infection (3 vs 4%; P = 0.68), re-exploration (8 vs 8%; P = 0.91) and in-hospital mortality (6 vs 4%; P = 0.92). Mid-term follow-up showed higher prosthetic valve calcification and/or sclerosis in NFS group (25 vs 6%; P = 0.015), whereas no significant differences were noticed between the two groups regarding stroke (0 vs 8%; P = 0.13), endocarditis (0 vs 4%; P = 0.50), 36- and 72-month survival (51 ± 2%, 14 ± 4% vs 55 ± 2%, 19 ± 3%, respectively; P = 0.45). CONCLUSIONS Aortic bioprostheses are a good option for haemodialysis patients requiring AVR, offering acceptable mid-term survival. The Medtronic Freestyle aortic bioprostheses could allow the implantation of larger bioprostheses inferring consequently lower mean gradients, with a potentially higher resistance to calcification and sclerosis in haemodialysis patients.

Current indications for stentless aortic bioprostheses

The best aortic prostheses have been debated for decades. The introduction of stentless aortic bioprostheses was aimed at improving hemodynamics and potentially the durability of aortic bioprostheses. Despite the good short- and long-term outcomes after implantation of stentless aortic bioprostheses, their use remains limited owing to the technically demanding implantation techniques. Nevertheless, stentless aortic bioprostheses might be of special benefit in certain indications, where they could be a valuable addition to the surgical armamentarium.

Impending rupture of the left atrium after impaction of left atrial ablation catheter.

A 60-year-old male presented with chronic atrial fibrillation. A trans-femoral catheter ablation was planned. The catheter was impacted in the left atrial wall (Fig. 1). Consequently, the procedure was interrupted before achieving resynchronisation. Catheter withdrawal was only possible after median sternotomy and closed manipulation of the catheter to release it.