Hemodynamic effects of elevation and stabilization of the heart during off-pump coronary surgery

Surgical approach to a left ventricular myxoma guided by transesophageal and epicardial dual-view echocardiography: a case report

Background

Left ventricular myxoma is a rare benign cardiac neoplasm. Surgical excision is the treatment of choice, and complete removal is mandatory to prevent late recurrence.

Case presentation

Here, we report a case of myxoma originating from the anterolateral wall of the left ventricle with a very short stalk. Accordingly, the transaortic and transmitral approaches were considered inadequate; therefore, a transventricular approach was adopted. To minimize the incidence of complications associated with a left ventriculotomy, its length was designed to be as short as possible. To plan a proper ventriculotomy, measurements were taken by the combined use of transesophageal echocardiography and epicardial direct echocardiography.

Conclusions

This method provided a good guide without being a complicated technique. The tumor and its attachment were clearly visualized and completely resected in an en bloc fashion. No recurrence has occurred to date.

Exposures of Lateral and Inferior Cardiac Surface for Coronary Anastomosis during Minimally Invasive Coronary Artery Bypass Grafting

Exposure of the lateral and inferior surface of the heart during off-pump coronary artery bypass grafting is associated with some degree of cardiac instability during recovery with completion of grafting. Exposure of lateral and posterior surfaces by currently available equipment is difficult in minimally invasive coronary artery bypass grafting (MICABG) owing to limited exposure. We describe an effective variation of often-used technique of pericardial stitch in exposure of cardiac surfaces during MICABG. This technique was used in 24 patients undergoing multivessel MICABG. Deep pericardial sutures were used to manipulate the exposure of cardiac surfaces. Left anterior descending artery was grafted in all 24 cases. Obtuse marginal artery was grafted in 20 cases and posterior descending artery in 12 cases. Average grafts were 2.3 per patient. There was no conversion to median sternotomy. Use of deep pericardial suture is simple technique for exposure of lateral and inferior surface during multivessel MICABG. This offers adequate exposure and operating space for easy maneuverability.

Multivessel awake off-pump coronary bypass grafting using median approach: technical considerations

OBJECTIVE

: Several reports of awake off-pump coronary artery bypass grafting (AOCAB) under high thoracic epidural anesthesia (TEA) for single-vessel grafts have been published, but few have described its application in multiple bypass procedures. We report the procedures and safety of AOCAB for multivessel disease.

METHODS

: Fifty-five multivessel AOCAB (52 men, 3 women; aged 68 ± 9.5 years) were performed at our hospital between 2003 and 2010. A medium sternotomy was made after TEA was established. During coronary artery anastomosis, a stabilizer and an apical suction device were used, and a coronary artery active perfusion system was used to maintain flow distal to the anastomosis. Pneumothorax due to pleural opening, when occurred, was repaired using Neoveil sheet and drainage tube.

RESULTS

: There was no operative death and no cerebral ischemia, cardiac arrhythmia, and chronic obstructive pulmonary disease. Operating time was 177 ± 35 minutes. Left internal thoracic artery was used in 55 anastomoses, right internal thoracic artery in 7, gastroepiploic artery in 17, radial artery in 48, and saphenous vein in 24. Time of anastomosis was 4.93 ± 0.92 minutes for left anterior descending coronary artery, 4.75 ± 1.21 minutes for circumflex artery, and 4.98 ± 1.02 minutes for right coronary artery. Intraprocedural pneumothorax occurred in 17 cases; 14 were repaired and nonintubated AOCAB was accomplished, 1 was intubated, and 2 had temporary assisted ventilation and laryngeal mask. Time to discharge was 15.5 ± 8.4 days.

CONCLUSIONS

: Multivessel AOCAB under TEA is not only feasible but also safe. Multiple grafts can be harvested under TEA, and complete vascularization is possible under constant monitoring of blood pressure and consciousness.

Hemodynamic changes during myocardial revascularization without extracorporeal circulation

BACKGROUND AND OBJECTIVES

Cardiac positioning and stabilization during myocardial revascularization without extracorporeal circulation (ECC) may cause hemodynamic changes dependent to the surgical site. The objective of this study was to evaluate these changes during distal coronary anastomosis.

METHODS

Twenty adult patients undergoing myocardial revascularization without ECC were monitored by pulmonary artery catheter and transesophageal Echo Doppler. Hemodynamic data were collected at the following times before removing the stabilizer wall: (1) after volume adjustments, (2) at the beginning of distal anastomosis, and (3) after 5 minutes. Treated coronary arteries were grouped according to their location in the lateral, anterior, or posterior wall. Two-way ANOVA with repetition and Newman-Keuls post-test were used in the analysis. A p value < 0.05 was considered statically significant.

RESULTS

During myocardial revascularization without ECC, pulmonary artery wedge pressure showed elevation from 17.7 ± 6.1 to 19.2 ± 6.5 (p < 0.001) and 19.4 ± 5.9 mmHg (p < 0.001), while the central venous pressure went from 13.9 ± 5.4 to 14.9 ± 5.9 mmHg (p = 0.007) and 15.1 ± 6.0 mmHg (p = 0.006). Intermittent cardiac output was reduced from 4.70 ± 1.43 to 4.23 ± 1.22 (p < 0.001) and 4.26 ± 1.25 L.min(-1) (p < 0.001). According to transesophageal Doppler, a significant group-time interaction was observed in cardiac output, which was reduced in the lateral group from 4.08 ± 1.99 to 2.84 ± 1.82 (p = 0.02) and 2.86 ± 1.73 L.min(-1) (p = 0.02), and aortic blood flow, which went from 2.85 ± 1.39 to 1.99 ± 1.26 (p = 0.02) and 2.00 ± 1.21 L.min(-1) (p = 0.02). Other hemodynamic changes were not observed during anastomoses.

CONCLUSIONS

A significant hemodynamic deterioration was observed during myocardial revascularization without ECC. Transesophageal Doppler detected a decrease in cardiac output only in the lateral group.

Training of Cardiac Surgeons for Bosnia and Herzegovina: Outcomes in Coronary Bypass Grafting Surgery

BACKGROUND

Bosnia and Herzegovina did not have invasive cardiac diagnosis or cardiac surgery before the recent war. With assistance from the United States and Norway, a cardiovascular clinic was developed. This study reports center-specific and surgeon-specific clinical outcomes. Since off-pump coronary bypass grafting surgery was prioritized in the treatment of coronary disease, a comparison was made between operations performed with and without cardiopulmonary bypass.

METHODS

Surgeons and key staff members were trained in the United States. A Norwegian data management system for cardiac surgery was implemented and cases entered after quality review of the data. A total of 1276 patients were entered; operations were performed with cardiopulmonary bypass in 540 and without in 736. The primary surgeon was entered as a variable in an anonymous fashion.

RESULTS

Overall mortality for coronary bypass grafting surgery was 1.6%, and the major complication rate was 4.5%. Patients operated on off-pump received fewer grafts and had a shorter length of stay. Unfavorable outcome was more common in patients when cardiopulmonary bypass was used in the operation. Regression analysis demonstrated that the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and use of cardiopulmonary bypass were predictors of poor outcome. The individual surgeon factor did not impact on outcomes.

CONCLUSIONS

Our study confirms that coronary artery bypass grafting surgery may be performed safely in a poor country in a hospital without experience with cardiac surgery. Selection of talented staff and cooperation with international cardiac centers are crucial. Off-pump coronary artery bypass grafting surgery is suitable for a new center and does not require more training than standard procedures.

Off-pump total arterial revascularization: our experience

BACKGROUND AND AIM

Off-pump coronary artery bypass grafting with both the internal thoracic arteries, such as the Tector technique, can reduce the morbidity associated with extracorporeal circulation and aortic cross-clamp. The aim of the present study is to describe our experience and the results obtained.

METHODS

From April 1998 to December 2003, the off-pump Tector technique was performed on 743 patients, of whom 621 were male (83.5%), with a mean age of 65.3 +/- 9.5 years (23-90). Preoperative risk factors were diabetes mellitus in 29.5% and peripheral vasculopathy in 14.7% of the patients. Angiography showed left main disease in 25.6% and triple-vessel disease in 50.3% of the patients, with a mean ejection fraction of 60%+/- 13% (23-88). Both the internal thoracic arteries were harvested using the skeletonization technique and were anastomosed as "Y" or "T" grafts. Intraoperative graft patency was checked using a Doppler flowmeter.

RESULTS

A total of 2028 distal anastomoses were performed, the average being 2.7 (1 to 5) per patient. At least three distal anastomoses were undertaken in 62% of the patients. Postoperative complications included atrial fibrillation in 40 patients (5.4%), myocardial infarction in 24 (3.2%), mediastinitis and reoperation for bleeding in 7 (0.9%) and stroke in 3 (0.4%). Twenty-four patients (3.2%) died in the first month postoperatively.

CONCLUSIONS

The off-pump Tector technique appears to be safe, showing a low surgical morbidity.

The History and Development of Direct Coronary Surgery without Cardiopulmonary Bypass*

The history of direct myocardial revascularization without cardiopulmonary bypass dates to 1961 in the dawn of coronary artery surgery. With the introduction and development of techniques of extracorporeal circulation around the same time, beating heart surgery was largely abandoned. Over the subsequent decades, cardiopulmonary bypass and electromechanical cardioplegic arrest became popular as means of revascularization in a bloodless and motionless field. While coronary artery surgery on the arrested heart remained undisputed for decades, myocardial revascularization on the beating heart was pursued by a few pioneering surgeons around the world, based on the belief that coronary revascularization could be performed equally well without the detrimental effects of cardiopulmonary bypass and electromechanical arrest. Various concepts and techniques developed during the 1980s by these pioneers enabled minimally invasive coronary surgery to be performed in the early 1990s. This break from the mainstream allowed selective myocardial revascularization using a minimal incision and no cardiopulmonary bypass to develop and constructed a base for future extensive revascularizations off-pump. With the subsequent explosion of new techniques for coronary exposure and myocardial stabilization, complete revascularization without cardiopulmonary bypass became possible with consistent results. Emerging from the preview of only a few surgeons just a decade ago, off-pump surgery is currently one of the accepted modalities for complete myocardial revascularization worldwide. This paradigm shift in the approach to myocardial revascularization has led to exiting new future possibilities, such as beating heart totally endoscopic coronary artery surgery.

Intraoperative and intermediate-term angiographic results of coronary artery bypass surgery with Symmetry proximal anastomotic device

OBJECTIVE

The objective of this study was to investigate the patency in saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices or with a traditional suture technique.

METHODS

Forty-six patients underwent coronary artery bypass grafting without cardiopulmonary bypass by using one thoracic graft and one or more saphenous vein grafts. Grafts were attached to the aorta with a Symmetry connector (St Jude Medical, Inc, St Paul, Minn) in 23 patients, and partial occlusion of the aorta and sutured anastomoses were used in 23 other patients. Grafts were studied intraoperatively with transit time flowmetry and angiography and revised if necessary. Angiography was repeated after 3 to 5 months.

RESULTS

Intraoperative graft patency did not differ between the 2 groups. Follow-up angiography demonstrated excellent thoracic graft patency. Vein graft patency decreased to 50% in the Symmetry group, whereas it was 90% in the suture group ( P = .01). Twenty-five percent of the Symmetry grafts had significant stenosis in the connector.

CONCLUSION

Saphenous vein grafts anastomosed to aorta with the Symmetry proximal connector have low intermediate patency compared with those with traditionally sutured anastomoses. We do not recommend the routine use of this device in coronary artery bypass operations.