Free internal mammary artery graft reimplantation on the same vessel in repeat coronary revascularization

We describe the case of a 62-year-old man who needed a 3-vessel coronary artery bypass reoperation and mitral valve replacement. The patient's existing free left internal mammary artery graft was not functioning because of a critical stenosis in the native vessel just after the distal anastomosis. The free graft itself was in perfect condition, and we decided to reuse it. Because the course of the graft was so tortuous, we concluded that skeletonization would yield the extra length needed for reimplantation. After reimplanting the graft, we performed venous grafting and mitral valve replacement. The patient was well and had no signs of ischemia at 29 months postoperatively. There have been few reports on recycling internal mammary artery grafts in repeat coronary artery bypass grafting. To our knowledge, ours is the first report of the reimplantation of a free internal mammary artery graft on the same vessel. We describe the procedure and our decision-making process.

Early outcomes of radial artery use in all-arterial grafting of the coronary arteries in patients 65 years and older

We retrospectively evaluated early clinical results of coronary revascularization using none but arterial grafts in patients aged 65 years and older. The cases of 449 consecutive patients who had undergone isolated myocardial revascularization were divided into 2 groups: the arterial conduit group (n=107) received a left internal mammary artery (LIMA) graft and 1 or both radial arteries (RAs), while the mixed-conduit group (n=342) received a LIMA graft and 1 or more saphenous vein grafts (SVGs), with or without an RA. There was no significant difference between the groups' rates of mortality. The arterial conduit group had a significantly shorter overall postoperative hospital stay than did the mixed-conduit group (mean, 6.6 +/- 0.9 vs 7.2 +/- 5 days; P=0.04). Linear regression analysis revealed that the presence of hypertension (beta=0.13; 95% confidence interval [CI], 0.054-0.759; P=0.02) and high EuroSCORE (beta=0.24; 95% CI, 0.053-0.283; P=0.004) were the major predicting factors for long hospital stay. Graft-harvest-site infection was statistically more frequent in the mixed-conduit group than in the arterial conduit group (6.4% vs 0, respectively; P=0.007). Angiography was performed postoperatively (mean, 24.9 +/- 16.3 mo; range, 11-65 mo) in 21 patients. In these patients, all LIMA grafts were patent, as were 86.9% of the SVGs and 90.9% of the RA grafts. Myocardial revascularization using all arterial grafts (at least 50% RAs) in patients aged 65 years and older is safe and reliable, produces short-term results equal to those of saphenous vein grafting, and can reduce graft-harvest-site infections.

Repair of coarctation-related aortic arch aneurysm and ventricular septal defect in an adolescent

A saccular aortic arch aneurysm that is secondary to aortic arch coarctation and that is accompanied by a ventricular septal defect is a rare combination in the adolescent patient. Total simultaneous repair of all of these conditions is desirable, because of the higher morbidity and mortality rates of staged procedures-particularly when resection of the saccular aneurysm is delayed. Herein, we discuss the case of a 16-year-old boy who underwent simultaneous surgical correction of these malformations. With the aid of cardiopulmonary bypass on the beating heart, the coarctation and the aneurysmal segment were resected, and a tubular Dacron graft was interposed. The ascending aorta and femoral artery were both then cannulated to ensure whole-body perfusion during cardiopulmonary bypass. The ventricular septal defect was closed with the patient under cardioplegic arrest. After 10 days, he was discharged from the hospital without sequelae. We conclude that single-staged repair of cardiac abnormalities and of an aortic arch aneurysm that is secondary to coarctation of the aortic arch can be performed safely and effectively in adolescent and adult patients by use of our technique.

Early outcomes of double-vessel coronary endarterectomy in comparison with single-vessel coronary endarterectomy

Our goal was to investigate the safety of single- and double-vessel coronary endarterectomy as an adjunct to coronary artery bypass grafting in patients with diffuse coronary disease. In reviewing the records of 9,443 patients who underwent isolated coronary artery revascularization over a 4-year period, we found 310 patients (3.28%) who underwent concomitant coronary artery endarterectomy, 39 of whom (12.6%) required double endarterectomy (Group 2) and the rest of whom required single endarterectomy (Group 1). Variables of these groups were compared by means of univariate analysis. In Group 1, 76.3% were men, with a mean age of 58.73 +/- 9.36 yr. Regarding postoperative myocardial infarction as evaluated by electrocardiography and the MB isoenzyme of creatine kinase, 13% of the patients in Group 1 and 15.4% in Group 2 were so affected. The early mortality rate was 3.3% in Group 1 and 10.3% in Group 2 (P <0.05). In univariate analysis, the following variables were significant: 3-vessel disease, postoperative atrial fibrillation, dialysis, length of hospital stay, and death. In multivariate analysis of endarterectomized arteries, the vascular combinations most strongly associated with death were left anterior descending coronary artery + right coronary artery and right coronary artery + diagonal. There was no association between endarterectomy of particular vessels and perioperative myocardial infarction. Although coronary endarterectomy has become a safe procedure, adding a 2nd endarterectomy worsens the prognosis dramatically, and surgeons should be especially cautious about such an addition if the 1st endarterectomy is in left anterior descending coronary artery or right coronary artery territory.

Coronary artery bypass grafting after pneumonectomy

When open-heart operations are necessary in patients who have undergone pneumonectomy, the unavoidable shift of mediastinal structures should be carefully considered. Surgical access, revascularization procedures, and the institution of cardiopulmonary bypass can all require approaches that differ from the usual. In particular, no general recommendations exist regarding the management of patients who undergo coronary artery bypass grafting after pneumonectomy. We successfully performed coronary artery bypass grafting in a 57-year-old man who had undergone a left pneumonectomy 7 years previously. Because the patient's heart was completely displaced into the left posterior hemithorax, access via a left posterolateral thoracotomy was chosen. Saphenous vein grafts were chosen over the internal mammary artery. The distal anastomoses were performed with use of the off-pump technique; for the proximal anastomosis, 2 venous grafts were implanted into the descending aorta. The patient's postoperative course was uneventful, and postoperative angiography revealed patent grafts. Herein, we discuss the case of this patient, and we present some considerations that can influence surgical approaches in similar circumstances.

Right coronary revascularization by coronary-coronary bypass with a segment of internal thoracic artery

In certain coronary artery bypass grafting operations, the internal thoracic artery is not by itself adequate for complete arterial revascularization. Which graft should be used for revascularization of the right coronary artery is still a matter of debate. From August 2000 through July 2005, we performed coronary-coronary bypass grafting on 48 patients (77.1% men, 22.9% women), whose mean age was 57.2 years (range, 40-75 yr). After completion of the internal thoracic artery anastomoses, we performed coronary-coronary bypass grafting with a remaining (distal) segment of the left (or, rarely, the full length of the free right) internal thoracic artery. The proximal and distal anastomoses of the internal thoracic artery to the right coronary artery were end-to-side. We preferred to use the right coronary ostium as the proximal anastomosis site where possible; otherwise, we used a disease-free segment of the right coronary artery. A total of 192 anastomoses were performed (mean, 4.15 per patient); all used the bilateral internal thoracic arteries as conduits. There were no in-hospital deaths or perioperative myocardial infarctions. The duration of follow-up ranged from 1 to 46 months (mean, 9.6 mo). Follow-up angiography was performed in 24 patients (50%). The mean time to coronary angiography was 16.5 months (range, 7 days-2 years). The patency rate was 100%. We conclude that coronary-coronary anastomosis by means of a distal segment of the internal thoracic artery can help to achieve complete arterial revascularization in selected patients.

Surgical approach for Stanford type A aortic dissection in a patient with Marfan syndrome and pectus excavatum

Acute Stanford type A aortic dissection in a patient with severe pectus excavatum constitutes a surgical emergency and presents a major challenge for the surgeon. Decisions must be made regarding the operative approach and whether the pectus excavatum should be corrected during the same session. Herein, we describe a case of acute aortic dissection in a patient who had Marfan syndrome with severe pectus excavatum. Combined partial upper sternotomy and left anterior thoracotomy provided excellent surgical exposure, and the aortic root and ascending aorta were completely replaced. The procedures were successful, and the patient recovered. Technical and surgical considerations led us to postpone concomitant correction of the pectus excavatum.

Immunohistochemical comparison of traditional and modified harvesting of the left internal mammary artery

The left internal mammary artery is the conduit of choice for coronary artery bypass grafting. In the traditional ("clipped-artery") harvesting technique, this artery is prepared as a pedicle; the distal part is clipped, cut, and covered with a papaverine-soaked cloth until anastomosis is performed. In modified ("nonclipped-artery") harvesting, the prepared artery is kept in situ and left connected to the systemic circulation until anastomosis. Better outcomes from use of the nonclip technique have been reported. In order to determine comparative endothelial integrity and endothelial nitric oxide synthase activity, we performed an immunohistochemical study of arterial graft segments that were procured by each technique. This cross-sectional study involved 40 patients who underwent elective coronary artery bypass grafting. The patients were randomized into 2 groups of 20. One group underwent traditional clipped-artery harvesting; the other group, modified nonclipped-artery harvesting. By immunohistochemical methods, we examined redundant segments taken from bifurcation levels of the arteries. The tunica media was thinner in the clipped arterial segments, a phenomenon that we attribute to high luminal pressure. Endothelial nitric oxide synthase immunostaining was absent in regions of denudation in the luminal endothelia of the clipped arteries; in contrast, pronounced immunostaining occurred in the endothelia of the nonclipped segments. We found that traditional harvesting disrupted the integrity of the luminal endothelia of the clipped arteries. In addition, the traditional procedure decreased nitric oxide production, as was revealed by immunostaining.

QTc interval prolongation predicts postoperative mortality in heart failure patients undergoing surgical revascularization

QTc interval prolongation is associated with increased mortality rates in patients with advanced heart failure. We investigated the predictive value of prolonged QTc interval in 567 patients with heart failure who were undergoing coronary artery bypass graft surgery The patients were in New York Heart Association class III or IV, with left ventricular ejection fractions of 0.40 or less. Before surgery, the QT interval duration was measured in leads II and V4 of the standard electrocardiogram and corrected by use of the Bazett formula. The QTc interval was prolonged (>440 msec) in 243 patients (43%) and normal in 324 (57%). The 2 study groups--prolonged QTc versus normal QTc--did not differ in terms of age (62 +/- 11 years vs 64 +/- 10 years, P=0.65), sex (80% male vs 76% male, P=0.31), ejection fraction (0.29 +/- 0.08 vs 0.29 +/- 0.09, P=0.72), hypertension (82% vs 78%, P=0.34), or diabetes (11% vs 7%, P=0.10). Within 1 month after coronary artery bypass grafting, 22 of 243 patients (9.1%) in the prolonged QTc group died, compared with 5 of 324 in the normal QTc group (1.5%) (P=0.0001). QTc interval prolongation was the only independent predictor of postoperative mortality on multivariate analysis (P=0.002). We conclude that patients with heart failure and preoperative QTc interval prolongation have increased mortality rates after coronary artery bypass grafting.

Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery

Postoperative glucose control directly affects the incidence of deep sternal wound infection and death after patients with diabetes have undergone coronary artery bypass grafting. We compared the effect upon glucose control of continuous insulin infusion with that of glucometer-guided insulin injection after coronary artery bypass. Our prospective, randomized, controlled study involved patients with diabetes mellitus who underwent coronary artery bypass grafting in our hospital from January 2001 through January 2003. Immediately after surgery, patients were randomly assigned to receive continuous insulin infusion or conventional glucometer-guided injection to maintain blood glucose at a level between 150 and 200 mg/dL. The adequacy of postoperative blood glucose control and clinical outcome were evaluated. Of 93 patients studied, the incidence of sternal wound infection was 3.9% among infusion patients and 4.8% among injection patients (P=0.587). There was no significant difference in mortality rates (infusion, 3.9%; injection, 2.4%; P=0.573). Satisfactory blood glucose levels were achieved in significantly more patients undergoing infusion than injection (64.7% vs 28.6%, P <0.001). In the injection group, significantly more blood glucose measurements were required to achieve control (23.4 vs 16.5, P=0.001), and good control was attained much sooner in the infusion group (21.4 vs 30.5 hr, P=0.013). We conclude that continuous insulin infusion provides better control of postoperative blood glucose levels after coronary artery bypass grafting in patients with diabetes than does glucometer-guided insulin injection.

Controversies in off-pump coronary artery surgery

Motivated by a desire to reduce the morbidity of a well-established and effective procedure for coronary artery disease, up to 25% of coronary artery bypass operations are being performed without the use of a heart-lung pump. Concerns remain about the quality of the coronary anastomoses and the completeness of revascularization. Randomized trials have not revealed the significant reduction in morbidity or mortality that the early enthusiasts had hoped for. Yet a number of non-randomized studies have shown clinical benefit from the avoidance of an extracorporeal circulation, but these have been criticized for potential bias in patient selection and management.A majority of surgeons have not yet adopted this technique and are waiting for the accumulation of more evidence.

Off-pump bypass surgery: the early experience, 1969-1985

This is a review of 733 patients who underwent off-pump bypass surgery of the right coronary artery and left anterior descending coronary artery between 1969 and 1985. Two hundred sixty-four patients underwent single bypass of the left anterior descending coronary artery, and 79 patients underwent single bypass of the right coronary artery. Both the left anterior descending and right coronary arteries were bypassed in 390 patients. In contrast to the present-day use of mechanical devices to stabilize the target vessel, a 4-suture surgical technique was used for this purpose. This technique, which we illustrate, proved less cumbersome and made the graft anastomosis easy to perform. Our early experience (1969 through 1972) in operating on 199 patients resulted in an operative mortality rate of 4.5% (9/199). From 1973 through 1985, improved patient selection and use of the left internal thoracic artery as the conduit of choice for bypass of the left anterior descending coronary artery reduced the operative mortality rate for 534 patients to 1.3% (7/534). Routine postoperative angiograms were not performed; therefore, the graft patency rate is not available. However, an ongoing 34-year follow-up study of the 264 patients who underwent a single left anterior descending bypass showed the saphenous vein graft to be open in 64.3% (18/28) patients and the left internal thoracic graft in 92.2% (59/64) of patients studied. Seventy-four of the 264 patients in this study were still alive in 2003.