Coronary Endarterectomy with Beating Heart in Patients with Diffuse Atheromatous Coronary Artery Disease and Poor Ventricular Function: Early and Midterm Results

Distal anastomosis support for bypass grafting with coronary endarterectomy for the severe diseased posterior descending artery

BACKGROUND

The posterior descending artery is the most common vessel chosen for an endarterectomy, while endarterectomy to the posterior descending artery is associated with decreased graft patency. The purpose of this study was to describe a distal anastomosis support (DAS) technique and retrospectively investigate the effect of DAS on the mid-term graft patency.

METHODS

Between January 2016 and December 2018, 200 patients with a PDA severe lesion who underwent off-pump coronary artery bypass (OPCAB) with CE (OPCAB + CE group, n = 95) and OPCAB + CE with DAS for anastomosis of PDA grafted by saphenous vein (SVG) (OPCAB + CE + DAS group, n = 105) were evaluated retrospectively. All patients came back to follow-up visit 6th, 12th, 24th, and 36th postoperative month. The primary endpoint is the graft failure (FitzGibbon B or O) of SVG-PDA on the follow-up CTA or CAG.

RESULTS

There was no significant difference in perioperative outcomes. We found significantly improved cumulative graft patency in OPCAB + CE + DAS group at 36 months after operation (84.6% vs 76.5%, p = 0.02). In multivariate Cox regression analysis, plaque length larger than 2 cm (hazard ratio [HR], 13.108, 95% confidence interval [CI], 2.842-60.457, p = 0.001), and peak TNI ⩾70× ULN within 48 hours of surgery (HR, 3.778, 95% CI, 1.453-9.823, p = 0.006) were independent predictors of graft failure, whereas PDA diameter greater than 1.5 mm (HR, 0.231, 95% CI, 0.081-0.654, p = 0.006), and DAS use (HR, 0.336, 95% CI, 0.139-0.812, p = 0.015) were significant protective factors.

CONCLUSIONS

Concomitant DAS conferred superior mid-term patency of SVG-PDA. Adding the DAS procedure to OPCAB + CE may be a promising surgical option for patients with a PDA severe lesion, especially when PDA diameter less than 1.5 mm and plaque length greater than 2 cm.

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting

OBJECTIVES

The aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events.

METHODS

A total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan-Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes.

RESULTS

The median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37-9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32-9.77; P = 0.013).

CONCLUSIONS

When performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.

Full Metal Jacket Endarterectomy of Left Anterior Descending Coronary Artery is Safe With Good Midterm Outcomes

BACKGROUND

Multiple overlapping stents (Full metal jacket, FMJ) from percutaneous coronary artery intervention (PCI) renders coronary artery bypass modus operandi unmanageable. We report our surgical revascularisation in patients with failed full metal jacket of left anterior descending coronary artery (FMJ-LAD).

METHODS

We reviewed 22 patients who presented with FMJ-LAD From 2006 to 2019. Extensive endarterectomy involving almost the whole length of the left anterior descending (LAD) was performed, the arteriotomy patched up with a saphenous vein. All reconstructed LADs were grafted with the left internal mammary artery. We compared the group to propensity-matched patients with single proximal LAD lesions requiring coronary artery bypass graft (CABG).

RESULTS

The mean age was 54±3.5 years. Twenty-one (21) patients (95%) were in angina class III or IV despite maximum medical therapy. Fourteen (14) patients (63.6%) presented with MI within 1 month. All patients had a preoperative positive test for ischaemia. Cross-clamp and bypass times were significantly shorter (25.5±7 mins and 65±5 mins, versus 52±3 mins and 77.2±4 mins) in the CABG group compared to FMJ-LAD group, the mean hospital stay of 6±1.5 days was not different between the groups. Postoperative electrocardiograms showed non-specific changes in 75% (n=16) with no enzyme rise. Early postoperative angiography was performed in 10 patients because of the new electrocardiograph (ECG) changes; all FMJ-LAD patients had an angiogram at 1 year, two late angiograms (2 and 3 years postoperatively), and one computed tomography (CT)-angiogram for readmission with angina. All patients in the FMJ-LAD group had 12 months follow-up angiogram or cardiac CT scan. All the endarterectomies' LADs were patent. There was no mortality within the 30 days. Patients' follow-up time was between 1-13 years.

CONCLUSIONS

Open stent endarterectomy is a valuable alternative option for patients with "full metal jacket" diseased LAD that is not graftable using standard techniques with acceptable midterm results.

Robotically assisted coronary endarterectomy

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.

Coronary Endarterectomy on Beating Heart: Is It Worth Doing?

BACKGROUND

Management of patients with severely impaired left ventricular function (LVF) associated with diffusely atheromatous coronary artery disease is a real dilemma. Coronary revascularization can be done only after endarterectomy to facilitate anastomosis. The aim of the present work is to present our experience and see whether performing endarterectomy during off-pump bypass can be of any benefit.

PATIENTS AND METHODS

Five patients with a mean ejection fraction of 27 +/- 4.5 underwent coronary revascularization facilitated by endarterectomy using off-pump technique. There were three males and two females with a mean age of 64.4 +/- 7.4 years. All patients were in NYHA class III or IV. Close endarterectomy was done to left anterior descending artery (LAD), right coronary artery (RCA), and intermediate artery.

RESULTS

All patients survived the procedure. A total of seven closed endarterectomies were performed. Five of these were done on LAD and the other two were done on RCA and intermediate artery. Two patients (40%) received inotropic support. One patient had perioperative infarction (20%). Mean follow-up period was 14.2 months +/- 19.7 (range, 1 month to 48 months). All patients were free of angina according to Canadian Cardiovascular Society and were in class NYHA I or II except one, who was in class III. Postoperative catheterization showed that all bypasses to endarterectomized arteries were patent. Patency rate was 83.4%. The mean postoperative ejection fraction was 29.8 +/- 6.9, which was not significantly different from preoperative one (p= 0.12).

CONCLUSION

Performing endarterectomy on beating heart in patients with compromised left ventricle is not an easy task. But it can be done with difficulty. Although the procedure is associated with high incidence of infarction, our early results, follow-up clinical status, and graft patency justify its use among patients with compromised left ventricular function who were previously considered inoperable.

Revascularization with off-pump coronary artery surgery: what appears new is actually the old rediscovered

The enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary artery bypass grafting. Several large retrospective analyses, meta-analyses, and the randomized trials that addressed different aspects of ONCAB and OPCAB to date have compared the two surgical strategies. It is suggested that patients may achieve an excellent outcome with either type of procedure, and individuals' outcomes more likely depend on factors other than whether they underwent ONCAB or OPCAB. Nevertheless, there appear to be trends in most studies. These trends include less blood loss and need for transfusion, less myocardial enzyme release up to 24 h, less early neurocognitive dysfunction, and less renal insufficiency after OPCAB and propensity to lower costs, thereafter proving OPCAB to be safe and clinically effective. Here, we review the physiological advantages and clinical outcomes of OPCAB for myocardial revascularization and examine whether either strategy is superior and in which patients.

Living with off-pump coronary artery surgery: evolution, development, and clinical potential for coronary heart disease patients

The enormous progress in interventional cardiology during the last 10 years has resulted in a major change in the spectrum of patients referred for coronary bypass surgery. These patients are older and sicker and frequently have had previous percutaneous coronary interventions. Consequently, cardiac surgery is responding by adding new surgical techniques: off-pump open-chest coronary bypass surgery (OPCAB), minithoracotomy bypass surgery, videothoracoscopic (robotic) procedures, etc. Several registries published to date have proved OPCAB to be safe and clinically effective. Randomized studies and meta-analysis research in this field provide scientific support and suggest that myocardial, renal, and neurological functions, amongst others, are better preserved by OPCAB than by classic techniques that use a cardiopulmonary bypass pump (CPB). Moreover, avoidance of CPB yields significantly reduced oxidative stress and systemic inflammatory response. This results in higher safety for ischemic heart disease patients undergoing revascularization, thus offsetting the propensity to lower costs. The present review examines the physiological advantages and clinical outcomes of this simple mode of myocardial revascularisation and evaluates the wider implications arising from its evolution.

Coronary endarterectomy in the current era

PURPOSE OF REVIEW

The increasing incidence of diffuse coronary artery disease in the current era challenges cardiac surgeons in accomplishing their goal of complete revascularisation. Although coronary endarterectomy is used with encouraging results in most institutions, there remains some controversy in its indications, technique, and results. The purpose of this review is to highlight the important evolutions of technique in the recent past.

RECENT FINDINGS

Despite the increased risk factors and comorbidities in patients presenting with diffuse coronary artery disease requiring coronary endarterectomy, the results of coronary endarterectomy are improving inline with the improvements in the results of conventional coronary artery bypass grafting surgery. The improving results of coronary endarterectomy in the left anterior descending artery are further clarified. The intra- and postoperative use of prostacyclin has been shown to be effective in reducing mortality and perioperative myocardial infarction. The technique of open coronary endarterectomy with on-lay patch bypass grafting has been shown to be safe and effective in reducing mortality and improving patency as compared with the closed (traction) method of coronary endarterectomy. The use of coronary endarterectomy was also found to be effective in the treatment of in-stent restenosis in the setting of diffuse coronary artery disease. The results of off-pump coronary endarterectomy are encouraging and comparable with the conventional coronary endarterectomy using cardiopulmonary bypass.

SUMMARY

With the increasing incidence of diffuse coronary artery disease and improving results of coronary endarterectomy, it is vital for cardiac surgeons to have coronary endarterectomy in their armamentarium to achieve complete coronary revascularisation.