Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting

Outcomes of 881 Consecutive Coronary Artery Bypass Graft Patients Using Heartstring Device

BACKGROUNDS

 One of the strategies to prevent stroke after coronary artery bypass grafting (CABG) may be the use of a device for proximal anastomosis without partial clamp of the ascending aorta.

METHODS

 We retrospectively investigated early and late outcomes in consecutive 881 patients undergoing isolated CABG using Heartstring for proximal anastomosis from January 2008 to December 2022, to reveal the validity to use it. All patients underwent preoperative imaging workups to evaluate neurovascular atherosclerosis.

RESULTS

 The mean age of the patients was 68.9 years, 20% were female and 13% had previous history of stroke. CABG was on-pump beating heart (52.2%) or off-pump (47.8%) with a mean number of distal anastomoses of 3.38 ± 0.93, using 1.62 ± 0.53 Heartstring devices under different aortic manipulations. In-hospital mortality was 2.0% and perioperative stroke rate was 0.9%, none of them died during hospital stay. During the follow-up period of 70 ± 47 months, the overall actuarial survival rates were 86 and 66%, and major adverse cardiac and cerebrovascular events (MACCEs)-free rates were 86 and 70% at 5 and 10 years, respectively. On multivariable analysis, risk factors for late death included male, previous history of stroke, postoperative sternomediastinitis, late new-onset stroke, and MACCEs, but did not include the perioperative stroke.

CONCLUSION

 Low stroke rate, as low as 0.9%, after CABG using Heartstring for proximal anastomosis, although under a variety of aortic manipulations, may contribute to the improved long-term prognosis.

Off-pump coronary artery bypass grafting with clampless aortic anastomosis devices: Aortic sealing devices versus automated anastomosis punching

Objectives

Clampless aortic anastomosis devices aim to lower stroke risk in off-pump coronary artery bypass grafting. Two main strategies for clampless anastomosis devices emerged with automated anastomosis punching and aortic sealing devices, prompting the question of perioperative outcome differences.

Methods

All consecutive patients undergoing elective off-pump coronary artery bypass grafting with a clampless aortic anastomosis device between September 2014 and December 2021 in 2 centers were retrospectively included. Cohorts were divided by the use of an automated anastomosis punching device or an aortic sealing device to achieve proximal anastomosis on the ascending aorta. To reach group comparability propensity score matching was performed. The primary end point was defined as a composite of all-cause mortality, stroke and rethoracotomy. Secondary end points were perioperative outcome parameters.

Results

A total of 3703 patients were enrolled of whom 575 and 3128 were included in the automated anastomosis punching and the aortic sealing device group, respectively. By propensity score matching a total of 1150 patients were included with 575 in each group. The primary composite endpoint showed no significant difference with 6.3% versus 5.9% events (odds ratio, 0.9; 95% confidence interval, 0.58-1.53, P = .81). All-cause mortality (P = .36), stroke (P = .81), and rethoracotomy (P = .89) also exhibit no disparity. Operation time was significantly longer in the aortic sealing device cohort with 220.0 ± 50.8 minutes and 204.6 ± 53.8 minutes (P < .01).

Conclusions

Clampless aortic anastomosis strategies aortic sealing device and automated anastomosis punching did not differ in perioperative outcome parameters, whereas the implementation of aortic sealing devices were associated with a prolonged operation time without inducing any inferior clinical outcome.

The Rationalisation of Intra-Operative Imaging During Cardiac Surgery: A Systematic Review

INTRODUCTION

One critical complication of cardiac surgery is cerebrovascular accidents (CVAs). Ascending aorta atherosclerosis poses a significant risk of embolisation to distal vessels and to cerebral arteries. Epi-aortic ultrasonography (EUS) is thought to offer a safe, high-quality accurate visualisation of the diseased aorta to guide the surgeon on the best surgical approach to the planned procedure and potentially improve neurological outcomes post-cardiac surgery.

METHOD

The authors conducted a comprehensive search of PubMed, Scopus and Embase. Studies that reported on epi-aortic ultrasound use in cardiac surgery were included. Major exclusion criteria were: (1) abstracts, conference presentations, editorials, literature reviews; (2) case series with <5 participants; (3) epi-aortic ultrasound in trauma or other surgeries.

RESULTS

A total of 59 studies and 48,255 patients were included in this review. Out of the studies that reported patient co-morbidities prior to cardiac surgery, 31.6% had diabetes, 59.5% had hyperlipidaemia and 66.1% had a diagnosis of hypertension. Of those that reported significant ascending aorta atherosclerosis found on EUS, this ranged from 8.3% of patients to 95.2% with a mean percentage of 37.8%. Hospital mortality ranged from 7% to 13%; four studies reported zero deaths. Long-term mortality and stroke rate varied significantly with hospital duration.

CONCLUSION

Current data have shown EUS to have superiority over manual palpation and transoesophageal echocardiography in the prevention of CVAs following cardiac surgery. Yet, EUS has not been implemented as a routine standard of care. Extensive adoption of EUS in clinical practice is warranted to aid large, randomised trials before making prospective conclusions on the efficacy of this screening method.

Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta?

OBJECTIVES

The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome.

DESIGN

A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio.

SETTING

At Isala Zwolle (NL), a large, nonacademic teaching hospital.

PARTICIPANTS

All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries.

INTERVENTIONS

The adaptation of surgical handling of the ascending aorta.

MEASUREMENTS AND MAIN RESULTS

In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79).

CONCLUSIONS

The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting

Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or “no-touch” techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.

Epiaortic Ultrasound for Assessment of Intraluminal Atheroma; Insights from the REGROUP Trial

OBJECTIVES

To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events.

DESIGN

Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest.

SETTING

Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting.

PARTICIPANTS

Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment.

INTERVENTIONS

Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping.

MEASUREMENTS AND MAIN RESULTS

Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% p = 0.523).

CONCLUSIONS

Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.

Does epiaortic ultrasound screening reduce perioperative stroke in patients undergoing coronary surgery? A topical review

Although the occurrence of stroke in patients undergoing coronary artery bypass grafting (CABG) is decreasing, it remains an important concern. Therefore, it is important to identify and adopt strategies that can decrease the incidence of stroke in these patients. One of the strategies that have demonstrated the potential to decrease the rate of post-CABG stroke is an assessment of aorta for atherosclerosis before surgery and changing the surgical plan accordingly to minimize the stroke risk. This assessment can be done through palpation of the aorta, transesophageal echocardiography (TEE), and epiaortic ultrasound scanning (EAS). EAS has shown superiority over both palpation and TEE for intraoperative evaluation of aorta. However, despite the evidence demonstrating reduced stroke rates with the EAS-guided approach, EAS is not yet the standard of care procedure in patients undergoing CABG. Therefore, we have reviewed the literature for evidence that supports the routine use of EAS in patients undergoing coronary surgery and have presented solutions to overcome the barriers to its routine use.

Modifying risks to improve outcome in cardiac surgery: An anesthesiologist's perspective

Challenging times are here for cardiac surgical and anesthesia team. The interventional cardiologist seem to have closed the flow of ‘good cases’ coming up for any of the surgery,; successful percutaneous interventions seem to be offering reasonable results in these patients, who therefore do not knock on the doors of the surgeons any more. It is a common experience among the cardiac anesthesiologists and surgeons that the type of the cases that come by now are high risk. That may be presence of comorbidities, ongoing medical therapies, unstable angina, uncontrolled heart failure and rhythm disturbances; and in patients with ischemic heart disease, the target coronaries are far from ideal. Several activities such as institution of preoperative supportive circulatory, ventilatory, and systemic disease control maneuvers seem to have helped improving the outcome of these ‘high risk ‘ patients. This review attempts to look at various interventions and the resulting improvement in outcomes. Several changes have happened in the realm of cardiac surgery and several more are en route. At times, for want of evidence, maximal optimization may not take place and the patient may encounter unfavorable outcomes.. This review is an attempt to bring the focus of the members of the cardiac surgical team on the value of preoperative optimization of risks to improve the outcome. The cardiac surgical patients may broadly be divided into adults undergoing coronary artery bypass graft surgery, valve surgery and pediatric patients undergoing repair/palliation of congenital heart ailments. Optimization of risks appear to be different in each genre of patients. This review also brings less often discussed issues such as anemia, nutritional issues and endocrine problems. The review is an attempt to data on ameliorating modifiable risk factors and altering non modifiable ones.

The use of intraoperative epiaortic ultrasonography in monitoring patients over 75 years old treated with aortic valve replacement

Introduction

Epiaortic ultrasound scanning (EAS) extended the use of ultrasound to the intraoperative diagnosis of aortic pathology. Surgical palpation of the ascending aorta underestimates the presence and severity of atherosclerotic plaques. Epiaortic ultrasound scanning has been used as an adjunct to transesophageal echocardiography (TEE) or as a primary direct diagnostic tool for imaging the ascending aorta as well as the aortic arch, which gained prominence as part of a multipronged intraoperative strategy to reduce atherosclerotic emboli.

Aim

To compare the epiaortic examination with transthoracic and transesophageal echo (transthoracic echocardiography (TTE) and TEE), X-ray, surgical intraoperative palpation, and postoperative neurological status.

Material and methods

The analyzed group consisted of 35 patients (mean age: 81.3 years) treated with aortic valve replacement (AVR), either alone (60%) or combined with coronary artery bypass grafting (CABG; 22.8%) or aortic aneurysm replacement (11.42%). In 2 patients, only CABG was performed because intraoperatively reevaluated strategy. Thierteen patients have got a history of diabetes, 10 chronic renal failure and 3 of cerebral stroke.

Results

In more than 80% of patients, positive EAS results had an influence on the choice of aortic clamping site and in 50% of patients on the site of cannulation. Female sex, peripheral vascular disease, history of previous stroke, and calcifications in the ascending aorta in TTE have significant predictive value for recognizing atherosclerotic changes in EAS and the risk of postoperative neurological complications in octogenarians treated with AVR.

Conclusions

Epiaortic ultrasound scanning imaging is superior to TTE and manual palpation in the detection and localization of ascending atherosclerosis. This technique should be introduced as a standard perioperative examination in older patients at risk of neurological complications.

Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years

INTRODUCTION

We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup.

MATERIAL AND METHOD

From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed.

RESULTS

We identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period.

CONCLUSION

Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Imaging Techniques for Diagnosis of Thoracic Aortic Atherosclerosis

The most severe complications after cardiac surgery are neurological complications including stroke which is often caused by emboli merging from atherosclerosis in the ascending aorta to the brain. Information about the thoracic aorta is crucial in reducing the embolization risk for both surgical open and closed chest procedures such as transaortic heart valve implantation. Several techniques are available to screen the ascending aorta, for example, transesophageal echocardiography (TEE), epiaortic ultrasound, TEE A-view method, manual palpation, computed tomography, and magnetic resonance imaging. This paper provides a description of the advantages and disadvantages of these imaging techniques.

Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects

Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.

Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass

Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah’s witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid–base alterations.

Innominate artery as an alternative site for proximal anastomoses in patients with a severely calcified aorta

BACKGROUND

Atheromatous plaques of the ascending aorta are one of the most important risk factors for postoperative mortality and morbidity in coronary artery bypass grafting (CABG). We have retrospectively analyzed the results of proximal anastomoses constructed on the innominate artery in patients with calcific atheromatous plaques (CAP) in their ascending aorta detected intraoperatively.

PATIENTS AND METHODS

This study is a retrospective review of 16 consecutive patients who underwent CABG operations and had CAP on their ascending aorta between November 2006 and June 2009. The atheromatous lesions were detected intraoperatively and the operation plan was changed to off-pump surgery. All the proximal anastomoses were made on the innominate artery, left internal thoracic artery (LITA) or the other saphenous vein grafts (SVG). Thirteen patients were male and three were female with a mean age of 63.7 ± 5.3 (ranged, 53-71) years.

RESULTS

A total of 56 distal anastomoses (3.5 per patient) and 25 proximal anastomoses on the innominate artery were performed. Of the 16 patients, seven (43.7%) had received a sequential SVG; two (12.5%) patients, sequential LITA graft; and one (6.25%) patient sequential SVG and LITA graft. One of the proximal anastomoses was performed on the SVG in four patients (25%) and on the LITA graft in one patient (6.2%). One patient (6.2%) died due to cerebrovascular morbidity. No other complications were observed.

CONCLUSIONS

The innominate artery is an alternative site for proximal anastomoses in patients with calcific atheromatous aorta.

Intraoperative epiaortic scanning for preventing early stroke after off-pump coronary artery bypass

BACKGROUND

Numerous studies have demonstrated the accuracy of epiaortic ultrasound scanning (EAS) for assessing ascending aortic disease. It remains unclear whether EAS changes the incidence of perioperative stroke after off-pump coronary artery bypass (OPCAB).

METHODS

We studied a retrospective cohort of 2292 patients who underwent isolated OPCAB from January 2001 to December 2011. Patients were retrospectively subdivided into two groups: the non-EAS group (n=1019) who underwent OPCAB under only intraoperative transoesophageal echocardiography and the EAS group (n=1273) who underwent OPCAB under EAS.

RESULTS

In the non-EAS group, 317 (31.1%) patients underwent OPCAB with partial aortic clamping and 702 (68.9%) underwent OPCAB without partial aorta clamping. In the EAS group, 301 (23.7%) patients underwent OPCAB with partial aortic clamping and 972 (76.3%) underwent OPCAB without partial aortic clamping. The incidence of early stroke was not different statistically between the EAS and non-EAS groups [non-EAS 1.7% (17/1019) vs EAS 0.8% (10/1273); P=0.052]. However, in the subgroups of patients with partial aorta clamping, the incidence of the early stroke was significantly lower in the EAS group [2.8% (9/317) vs 0.7% (2/301) P=0.041].

CONCLUSIONS

EAS has a significant clinical benefit in reducing the incidence of early stroke in cases of partial aortic clamping in OPCAB. Therefore, EAS should be considered in patients who need partial aortic clamping in OPCAB.

A case report and brief review of the literature on bilateral retinal infarction following cardiopulmonary bypass for coronary artery bypass grafting

Postoperative visual loss is a devastating perioperative complication. The commonest aetiologies are anterior ischaemic optic neuropathy (AION), posterior ischaemic optic neuropathy (PION), and central retinal artery occlusion (CRAO). These appear to be related to certain types of operation, most commonly spinal and cardiac bypass procedures; with the rest divided between: major trauma causing excessive blood loss; head/neck and nasal or sinus surgery; major vascular procedures (aortic aneurysm repair, aorto-bifemoral bypass); general surgery; urology; gynaecology; liposuction; liver transplantation and duration of surgery. The non-surgical risk factors are multifactorial: advanced age, prolonged postoperative anaemia, positioning (supine v prone), alteration of venous drainage of the retina, hypertension, smoking, atherosclerosis, hyperlipidaemia, diabetes, hypercoagulability, hypotension, blood loss and large volume resuscitation. Other important cardiac causes are septic emboli from bacterial endocarditis and emboli caused by atrial myxomata. The majority of AION cases occur during CPB followed by head/neck surgery and prone spine surgery. CPB is used to allow coronary artery bypass grafting on a motionless heart. It has many side-effects and complications associated with its use and we report here a case of bilateral retinal infarction during routine coronary artery bypass grafting in a young male patient with multiple risk factors for developing this complication despite steps to minimise its occurrence.

Second Internal Thoracic Artery Versus Radial Artery in Coronary Artery Bypass Grafting

Background—

The best second arterial conduit for multiple arterial revascularization (MAR) is still a matter of debate. Previous studies on the benefit of either using the radial artery (RA) or the right internal thoracic artery (RITA) in coronary artery bypass grafting are not conclusive. The aim of our study was to compare the perioperative and long-term outcome of either RA or RITA grafts as second conduits for MAR.

Methods and Results—

A consecutive series of 1001 patients undergoing first nonemergent coronary artery bypass grafting receiving either RA or RITA as second graft for MAR between 2001 and 2010 were studied. There were 277 patients receiving a RITA and 724 patients receiving a RA in addition to a left internal thoracic artery (LITA). Concomitant saphenous vein grafts (SVG) were grafted in addition as necessary. Propensity score–matched analysis was performed to compare the 2 groups, bilateral ITA±SVG (BITA±SVG group) and the LITA+RA±SVG group relative to overall survival and major adverse cardiac and cerebrovascular events–free survival. Hazard ratios and their 95% confidence intervals were estimated by COX regression stratified on matched pairs. The incidence of perioperative major adverse cardiac and cerebrovascular events was significantly lower in the BITA±SVG group (1.4% versus 7.6%, P <0.001). Overall survival (hazard ratio 0.23; 95% confidence interval 0.066–0.81; P =0.022) and major adverse cardiac and cerebrovascular events–free survival (hazard ratio 0.18; 95% confidence interval 0.08–0.42; P <0.001) were significantly better in the BITA±SVG group compared to the LITA+RA±SVG group.

Conclusions—

The results of our study provide strong evidence for the superiority of a RITA graft compared to RA as a second conduit in MAR.

Improve morbidity and mortality in coronary artery bypass graft surgery for severe atherosclerosis

OBJECTIVES

Atherosclerosis has been identified as a risk factor for both morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). To investigate outcomes following CABG for severe atherosclerosis, and to determine whether different surgical techniques can reduce the risk of neurologic events in these patients.

METHODS

We studied 225 consecutive patients who underwent elective isolated CABG. Routine preoperative and intraoperative examinations identified patients with severe atherosclerosis. We compared the outcomes between patients with (group A; 42 ceses) and those without (group N; 183 cases) severe atherosclerosis.

RESULTS

36 patients (85.7%) in group A and 176 (96.2%) in group N underwent off-pump coronary artery bypass (OPCAB); 6 (14.3%) in group A and 7 (3.8%) in group N underwent on-pump beating CABG. Three patients in group A suffered deep sternal infection (7.1%), and one suffered stroke (2.4%) compared with none in group N. No cerebral infarction or neurologic events occurred in patients who underwent OPCAB (n = 212, 94.2%).

CONCLUSIONS

Prevalence of complications was significantly greater among patients with severe atherosclerotic disease who underwent OPCAB than in those without atherosclerotic disease. Careful selection of surgical strategies can prevent perioperative stroke and reduce mortality.

“Beyond Beating Heart Surgery” Heartstring Device Protects against Perioperative Neurological Events

Objective

There is a growing body of evidence favoring off-pump coronary artery bypass surgery (OPCAB) over traditional coronary artery bypass surgery (CABG) with cardiopulmonary bypass as a method for reducing perioperative neurologic events. Aortic manipulation, whether with OPCAB or coronary artery bypass surgery with cardiopulmonary bypass, is strongly linked with adverse neurologic outcomes. Although the aortic “no-touch” technique has merit, most cardiac surgeons are reluctant to base entire myocardial revascularization exclusively on mammary pedicles. The purpose of this study was to analyze our experience with OPCAB combined with the use of a Heartstring proximal anastomotic device, as a strategy for reducing clinically evident cerebrovascular accidents.

Methods

Two hundred twenty-seven consecutive isolated OPCAB were performed without the use of a side-biting aortic clamp. In all these operations, a Heartstring device was used, permitting clampless hand-sutured proximal anastomoses. All patients were managed in this fashion regardless of the status of their ascending aorta. A mean of 3.4 bypasses were performed during each operation, with one or two mammary arteries harvested routinely. In 98% of patients, a single proximal anastomosis was performed; there was liberal use of sequential bypass grafts.

Results

Mean age was 69.3 years, with 17% octogenarians. Preexisting cerebrovascular disease was present in 22.4% of patients. There were no clinically evident perioperative neurologic events in any patients. There were no operative deaths.

Conclusions

This series suggests that OPCAB performed with a single, clampless, proximal aortic anastomosis, and with a Heartstring device may protect against perioperative strokes.

Current role and outcomes of ascending aortic replacement for severe nonaneurysmal aortic atherosclerosis

BACKGROUND

Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures.

METHODS

Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 +/- 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases.

RESULTS

Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% +/- 4%, 74% +/- 6%, and 68% +/- 8%, respectively.

CONCLUSIONS

Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.

Correlation between pre-operative brain magnetic resonance angiography findings and intra-operative cerebral oxygen saturation during coronary artery bypass graft surgery

Coronary artery bypass graft (CABG) patients often have cerebrovascular disease and pre-operative brain magnetic resonance angiography (MRA) frequently reveals cerebral vasculature stenosis. This study was designed to investigate whether pre-operative MRA findings correlated with regional cerebral oxygen saturation (ScO(2)) in 120 patients undergoing on-pump or off-pump CABG. Following MRA examination, patients were divided into six groups of 20 patients each based on MRA findings (no stenosis, mild stenosis or severe stenosis) and procedure (on-pump or off-pump CABG). Mean ScO(2) values over 3 min were determined at seven periods during surgery. Patients with severe cerebrovascular stenosis showed significantly lower ScO(2) than other groups during off-pump CABG. During on-pump CABG, ScO(2) decreased significantly during cardiopulmonary bypass in all groups and was significantly lower in the severe stenosis group. Pre-operative MRA and intra-operative ScO(2) monitoring may help to identify patients at increased risk of brain damage during or following CABG.

Epiaortic ultrasound assessment of the aorta in cardiac surgery

The dislodgement of atheroma from the ascending aorta and proximal arch is a major cause of stroke and neurological injury following cardiac surgery. The accurate detection of atheroma prior to aortic manipulation is necessary to facilitate surgical strategies to reduce the risk of embolisation. The traditional method for atheroma detection is manual palpation by the surgeon. This technique misses about half the number of the atheroma lesions, as the soft (non-calcified) lesions offer little resistance to the surgeon's fingers. Trans-oesophageal echocardiography (TOE) is commonly used in cardiac surgery, but the interposition of the bronchus between the aorta and the oesophagus causes an ultrasound 'blind spot' in the ascending aorta and proximal arch, such that it does not offer improved detection compared to manual palpation. Accurate detection of atheroma requires direct ultrasound assessment using epiaortic scanning, with a high-frequency, linear-array probe. This allows the surgeon to correctly assess and localise any atheroma. In this article, a suggested epiaortic examination sequence is described and strategies for surgeons to avoid atheroma are discussed.

Novel surgical method of proximal anastomosis in off-pump coronary artery bypass grafting

BACKGROUND

Cerebral embolization as a result of aortic manipulation has emerged as an important risk factor for the incidence of stroke after off-pump coronary artery bypass grafting (OPACB).

METHODS AND RESULTS

A new surgical technique for proximal anastomosis without using a side-biting clamp or any proximal anastomotic device in OPACB has been developed and successfully used for proximal anastomosis between a great saphenous vein or radial artery graft and the aorta in OPCAB of 138 patients, with good short-term results.

CONCLUSIONS

This novel technique proximal anastomosis in OPACB can be completed in a safe, easy and economical fashion.

Safer aortic crossclamping during short-term moderate hypothermic circulatory arrest for cardiac surgery in patients with a bad ascending aorta

OBJECTIVE

Cardiac surgery in patients with severely atherosclerotic or porcelain ascending aorta is technically challenging, with markedly increased risk of atheroembolism. We describe a technique of meticulous crossclamping of a difficult aorta during short-term moderate hypothermic circulatory arrest.

METHODS

From 1997 to 2007, we found 40 patients (mean age, 70 +/- 8 years), including 14 patients undergoing hemodialysis, whose preoperative computed tomographic and intraoperative epiaortic ultrasonographic scans revealed eggshell calcification (n = 15) or protruding atheromas (n = 25) of the ascending aorta. They underwent cardiac surgery (aortic, 31 patients; mitral, 3 patients; both, 5 patients; and coronary alone, 1 patient) by means of meticulous crossclamping during hypothermic circulatory arrest for 3.4 +/- 1.5 minutes at a rectal temperature of 29.0 degrees C +/- 2.3 degrees C. During hypothermic circulatory arrest, we performed only internal inspection to identify the safe location of crossclamping in 21 patients, whereas we required debridement of calcification or atheroma by using the Cavitron Ultrasonic Surgical Aspirator (Tyco Healthcare, Mansfield, Mass) for safe crossclamping in 19 patients.

RESULTS

By using this technique, no patients died during the hospital stay. Stroke occurred in 1 (2.5%) patient, and transient agitation occurred in 1 patient. Re-exploration for bleeding was required in 1 patient, and wound infection occurred in 2 patients. During follow-up, with a median time of 5.2 years, the overall survival rates were 100%, 90%, and 76% at 1, 3, and 5 years, respectively. Three patients required reoperations during the follow-up period because of pseudoaneurysm in 2 patients and prosthetic valve infection in 1 patient.

CONCLUSION

Short-term moderate hypothermic circulatory arrest is quite useful for safe aortic crossclamping after internal inspection or debridement in high-risk patients with a severely atherosclerotic aorta.

Intra–aortic Filtration in Cardiac Surgery

Cardiac surgery is associated with a significant risk of adverse outcomes, particularly neurologic and renal. Embolic events are the primary source of these deleterious consequences. Intraaortic filtration is the only current technology shown to effectively capture particulates released during cardiac procedures and decrease morbidity and mortality. Although most surgical candidates may potentially benefit from intraaortic filtration, some patients are more likely to experience improved outcomes. Based on the evidence reported in the literature and the extensive experience of the authors, the following opinion details the authors’ rationale and recommendations for patient selection for intraaortic filtration during cardiac surgery.

An Argument for Routine Ultrasound Screening of the Thoracic Aorta in the Cardiac Surgery Population

Stroke and neurological injury are among the most devastating and disabling complications associated with cardiac surgery. Transesophageal echocardiography and epiaortic ultrasound allow for sensitive, point-of-care diagnosis of thoracic aortic disease, which is especially common in patients with heart disease. Unlike other operative procedures, the manipulation of the ascending aorta is routine in cardiac surgery and often unavoidable. Dislodgement and embolization from the ascending and aortic arch atheromas have been clearly associated with manipulation during cardiac surgery. Epiaortic ultrasound and transesophageal echocardiography screening are more accurate and more accessible to the operative team than any other available modality to diagnose atherosclerosis of the aorta. The goal of this review is to review the rationale and scientific evidence that suggests that the routine use of ultrasound guidance in cardiac surgery may improve postoperative outcomes in this patient population.

The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients

BACKGROUND

Intraoperative echocardiography has become a mainstay monitor of cardiac function and a popular diagnostic tool in patients undergoing cardiac procedures. Previous reports suggest that epiaortic ultrasonography (EU) is superior to transesophageal echocardiography and manual palpation in identifying ascending aortic atheroma. Its impact on surgical decision making has not been thoroughly investigated, however.

METHODS

We retrospectively analyzed the medical records of 6051 consecutive patients who underwent EU of their ascending aorta during cardiac operations between 1996 and 2006 to determine a potential impact on intraoperative surgical decision making. Aortic atheroma was graded according to standard classification. Neurologic complications were evaluated according to the Society of Thoracic Surgeon definition for stroke and transient ischemic attack (TIA).

RESULTS

The overall impact of EU on surgical decision making was 4.1% and included a change in the technique for inducing cardiac arrest in 1.8%, aortic atherectomy or replacement surgery in 0.8%, requirement for off-pump coronary artery bypass grafting (CABG) in 0.6%, avoidance of aortic cross-clamping and use of ventricular fibrillatory arrest in 0.5%, change in arterial cannulation site in 0.2%, or avoidance of aortic cannulation in 0.2%. The greatest affect of EU was observed in patients undergoing combined CABG with aortic/mitral valve procedures (6.7%). The smallest impact was seen in patients undergoing mitral valve operations (1.4%). Aortic atheroma was more frequent on the anterior aspect of the aorta (n = 171) in patients with a change in surgical plan than on the posterior aspect (n = 78). The overall stroke rate was lower in patients with intraoperative EU compared with all patients undergoing surgical procedures.

CONCLUSIONS

Epiaortic ultrasonography is a useful technique to detect ascending aortic atheroma, has a significant impact on surgical decision making in more than 4% of cardiac surgical patients, and might result in improved perioperative neurologic outcome.

Gaseous and solid cerebral microembolization during proximal aortic anastomoses in off-pump coronary surgery: the effect of an aortic side-biting clamp and two clampless devices

OBJECTIVES

Intraoperative cerebral microembolism is a cause of cerebral dysfunction after cardiac surgery, and particulate microemboli are the most damaging. Using a new-generation transcranial Doppler ultrasound, we compared the number and nature of microemboli in patients undergoing off-pump coronary artery bypass grafting during performance of proximal anastomoses with three techniques: an aortic side-biting clamp and two clampless devices (the Enclose II device [Novare Surgical Systems, Inc, Cupertino, Calif] and the Heartstring II device [Guidant Corporation, Santa Clara, Calif]) developed to obviate the need for an aortic side-biting clamp, thereby reducing the number of cerebral microemboli.

METHODS

Bilateral continuous monitoring of the middle cerebral arteries was performed with a multirange, multifrequency transcranial Doppler device that both automatically rejects artifacts online and discriminates between solid and gaseous microemboli. Recordings were continuously undertaken during performance of 66 proximal aortic anastomoses in 42 patients. Thirty-five anastomoses were performed with an aortic side-biting clamp, 20 with the Enclose device, and 11 the Hearstring device.

RESULTS

Most microemboli occurred during application/insertion and removal of each device from the ascending aorta. The median number (interquartile range) of total microemboli was 11 (6-32) during side clamping, 11 (6-15) with the Enclose device, 40 (31-48) with the Heartstring device (P < .01). The proportion of solid microemboli was significantly higher in the side-clamp group (23%) compared with 6% and 1% in the Enclose and Heartstring groups, respectively (P < .01).

CONCLUSIONS

Avoidance of aortic side clamping results in a significant reduction in the proportion of solid microemboli detected with transcranial Doppler. As solid microemboli are probably the most damaging, use of the Enclose and Heartstring devices may represent an important strategy for minimizing cerebral injury during proximal aortic anastomoses.