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Bakhos JJ, Iacona GM, Koprivanac M, Tong MZ, Unai S, Soltesz EG, Elgharably H, Bakaeen FG. Internal Thoracic Arteries Injuries During Harvesting: Mitigation and Management. Semin Thorac Cardiovasc Surg 2024:S1043-0679(24)00075-3. [PMID: 39304036 DOI: 10.1053/j.semtcvs.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 08/23/2024] [Indexed: 09/22/2024]
Affiliation(s)
- Jules J Bakhos
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gabriele M Iacona
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Coronary Artery Disease Center, Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Mezzetto L, D'Oria M, Mastrorilli D, Grosso L, Agresti L, Griselli F, Frigatti P, Lepidi S, Veraldi GF. Intraoperative Transit-Time Flow as a Predictor of Failure after Infrainguinal Revascularization with Heparin-Bonded Expanded Polytetrafluoroethylene Graft. Ann Vasc Surg 2024; 106:273-283. [PMID: 38821469 DOI: 10.1016/j.avsg.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND The heparin-bonded expanded polytetrafluoroethylene (He-ePTFE) conduit is an option for patients requiring infrainguinal revascularization (iIR), but the risk of failure may be unpredictable, especially in cases with poor run-off. Intraoperative transit-time flow (TTF) provides an automated and quantitative analysis of flow and may serve as an adjunct evaluation during surgical revascularization. The aim of this study was to assess TTF in patients undergoing iIR with He-PTFE at 3 referral hospitals and to establish a predictive flow threshold for graft occlusion. METHODS A prospective registry initiated in 2020 enrolled patients undergoing iIR using He-PTFE for critical limb ischemia or severe claudication, and TTF measurement was analyzed. Preoperative assessments of anatomical and clinical characteristics were available for all patients. The HT353 Optima Meter (Transonic Systems Inc., Ithaca, NY, USA) was used in all procedures according to a standardized protocol. The institutional ethics committee approved the study. A predictive model using receiver operating characteristic curve analysis was utilized to establish the threshold of flow, and variables were compared. Anatomical and clinical evaluation were reported according to Rutherford grade, Global Limb Anatomic System and Wound, Ischemia, and foot Infection classification. The main outcome considered was the correlation between TTF and graft occlusion. Secondary outcomes included survival, other predictors of graft occlusion, freedom from major adverse cardiovascular events, and freedom from major amputation. RESULTS Among 68 patients, 55.8% had Rutherford 5-6, 45.6% had Global Limb Anatomic System 3 and 73.5% had Wound, Ischemia, and foot Infection 3-4. Distal anastomosis was at tibial level in 23.5% and mean diameter of conduit was 6.4 mm. Basal and postoperative TTF were 27.8 ± 15.6 ml/min and 109.0 ± 53.0 ml/min, respectively. After a mean follow-up of 18 ± 13 months, 7 (10.9%) patients presented graft occlusion and 5 (7.8%) required major amputation. TTF threshold = 80 ml/min revealed a sensitivity and specificity of 81.8% (95% confidence interval 48.2-97.7) and 80.7% (95% confidence interval 68.1-90.0) respectively, and it was selected as cut-off for graft occlusion. Freedom from graft occlusion in patients with TTF >80 ml/min vs. TTF ≤80 ml/min at 6, 12, and 24 months was 95.7% (standard error (SE) = 0.030) vs. 65.5% (SE = 0.115), 95.7% (SE = 0.030) vs. 58.9% (SE = 0.120) and 90.9% (SE = 0.054) vs. 51.6% (SE = 0.126), P = 0.0003. No statistical difference in primary patency, secondary patency and limb salvage was observed. At multivariate analysis, distal anastomosis at tibial vessel (odds ratio 8.50) and TTF ≤80 ml/min (odds ratio 9.39) were independent predictors of graft occlusion. CONCLUSIONS These results suggest that TTF may serve as a valuable tool in the management of iIR. A TTF measurement of ≤80 ml/min should be regarded as a predictor of graft occlusion, prompting consideration of additional intraoperative maneuvers to enhance arterial flow. Caution should be exercised in patients requiring direct tibial artery revascularization, as it represents a predictor of failure independent of TTF levels. Larger cohorts of patients and longer follow-up periods are necessary to confirm these findings.
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Affiliation(s)
- Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy.
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, University Health Agency Giuliano-Isontina, Trieste, Italy
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Lorenzo Grosso
- Unit of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Luigi Agresti
- Unit of Vascular and Endovascular Surgery, General Surgery Department, ASUFC, Hospital of Udine, Udine, Italy
| | - Filippo Griselli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, University Health Agency Giuliano-Isontina, Trieste, Italy
| | - Paolo Frigatti
- Unit of Vascular and Endovascular Surgery, General Surgery Department, ASUFC, Hospital of Udine, Udine, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, University Health Agency Giuliano-Isontina, Trieste, Italy
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
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Kozlov BN, Zatolokin VV, Mochula AV, Alisherov Y, Panfilov DS, Kamenshchikov NO, Kim EB. Intraoperative Prediction of Coronary Graft Failure Based on Transit Time Flow Measurement: A PRELIMINARY STUDY. Diagnostics (Basel) 2024; 14:1903. [PMID: 39272686 PMCID: PMC11394108 DOI: 10.3390/diagnostics14171903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/20/2024] [Accepted: 08/28/2024] [Indexed: 09/15/2024] Open
Abstract
Myocardial revascularization has been known to not affect the prognosis in some patients. Coronary artery bypass graft (CABG) failure may develop one year after CABG surgery. This is accompanied by a high risk of developing myocardial infarction after complete myocardial revascularization in obstructive coronary artery disease (CAD) due to microvascular dysfunction. The study of microvascular dysfunction using intraoperative stress tests with adenosine triphosphate (ATP) allows for the assessment of the coronary bypass flow reserve (CBFR) and the risk of graft failure one year after surgery. The study included 79 CAD patients (238 grafts) who underwent dynamic single-photon emission computed tomography (SPECT) before CABG and dynamic transit time flow measurement (TTFM) during CABG at rest and at stress. The CBFR was calculated by the ratio of the mean graft flow (MGF) at stress to the MGF at rest. A multivariate regression model showed that the MGF at rest (p = 0.043), the MGF at stress (p = 0.026) and the CBFR (p = 0.0001) were significant independent predictors of graft failure. As a result of ROC analysis, the threshold CBFR < 1.67 units correlated with graft failure more closely (sensitivity 82%, specificity 90%) The CBFR is a significant independent predictor of graft failure for up to 16 months.
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Affiliation(s)
- Boris N Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
| | - Vasily V Zatolokin
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
| | - Andrew V Mochula
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
| | - Yusufjon Alisherov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
| | - Dmitri S Panfilov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
| | - Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
| | - Elena B Kim
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia
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Ruel M. The 10 Commandments of Less Invasive CABG: How to Increase Adoption. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241272159. [PMID: 39185597 DOI: 10.1177/15569845241272159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Affiliation(s)
- Marc Ruel
- University of Ottawa Heart Institute, ON, Canada
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Wang W, Liu Y, Qi H, Liu Y, Jiang Y, Fan R, Shao J, Chen W, Su C, Chen X. Mid-term outcomes of endoscopic vein harvesting in coronary artery bypass grafting: a retrospective cohort study. J Cardiothorac Surg 2024; 19:389. [PMID: 38926738 PMCID: PMC11210013 DOI: 10.1186/s13019-024-02930-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVES Endoscopic vein harvesting (EVH) is an alternative technique to obtain the saphenous vein for coronary artery bypass grafting (CABG) surgery. We aimed to evaluate the early and mid-term outcomes of patients with EVH in CABG. METHODS This cohort study included consecutive isolated CABG patients in Nanjing First Hospital from July 2020 to December 2022 using propensity score matching methods. Patients were classified to EVH group and open vein harvesting (OVH) group according to the vein harvesting methods. The primary outcome was the all-cause death, and the secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, heart failure, myocardial infarction and revascularization and asymptomatic survival in the follow-up. RESULTS Totally 1247 patients were included in the study with 849 in OVH group and 398 in EVH group. Patients with EVH were more female, diabetes, higher body mass index, more multi-vessel and left main diseases. 308 pairs were formed after the matching. There was no significant difference in the rates of in-hospital death (EVH vs. OVH, 2.3% vs. 1.3%, P = 0.543). During the 3 years follow-up, EVH grafts were considered not inferior to OVH grafts, no differences were found in all-cause death [8.5% vs. 5.0%, hazard ratio (HR) 1.565, 95% confidence interval (CI): 0.77-3.17, P = 0.21], MACEs (8.1% vs. 7.1%, HR 1.165, 95CI: 0.51-2.69, P = 0.71) and asymptomatic survival (66.7% vs. 72.5%, HR 1.117, 95%CI: 0.65-1.92, P = 0.68). CONCLUSIONS EVH grafts were considered comparable to OVH grafts in patients following CABG in the 3 years follow-up.
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Affiliation(s)
- Wuwei Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Yiming Liu
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Haoyu Qi
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Yafeng Liu
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Yunfei Jiang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Rui Fan
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Junjie Shao
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Wen Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China.
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Changle Road 68, Nanjing, China.
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Gikandi A, Stock E, DeMatt E, Hirji S, Awtry J, Quin JA, Tolis G, Biswas K, Zenati MA. Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes. Eur J Cardiothorac Surg 2024; 65:ezae155. [PMID: 38598201 DOI: 10.1093/ejcts/ezae155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/06/2024] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis. METHODS This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations. RESULTS Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses. CONCLUSIONS Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.
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Affiliation(s)
- Ajami Gikandi
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eileen Stock
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Ellen DeMatt
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jake Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jacquelyn A Quin
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Leviner DB, Puskas JD, Taggart DP. Transient time flow measurement in arterial grafts. J Cardiothorac Surg 2024; 19:224. [PMID: 38627771 PMCID: PMC11020465 DOI: 10.1186/s13019-024-02670-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
Coronary artery bypass grafting (CABG) is one of the foundations of treatment for coronary artery disease. While it has improved substantially since its inception more than 50 years ago, including a rising use of multiple arterial grafting, intraoperative quality assessment is yet to be disseminated as an integral part of the procedure. Herein we review the fundamentals of intraoperative quality assessment in CABG using transient time flow measurement (TTFM) with a focus on its use in arterial grafting.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiac Surgery, Carmel Medical Center, Haifa, Israel.
- The Ruth & Baruch Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - John D Puskas
- Devision of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
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8
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Ruel M, Gupta S, Ponnambalam M, Chong AY. Less Invasive and Hybrid Surgical/Interventional Coronary Disease Management: The Future Is Now. Can J Cardiol 2024; 40:290-299. [PMID: 38070770 DOI: 10.1016/j.cjca.2023.11.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/26/2023] [Accepted: 11/26/2023] [Indexed: 01/14/2024] Open
Abstract
Coronary artery bypass grafting (CABG) has evolved to become the criterion standard in elective revascularisation for coronary artery disease (CAD), particularly in patients with complex or multivessel CAD, left main involvement, diabetes mellitus, or left ventricular dysfunction. Despite the superiority of CABG in patients with the most advanced forms of CAD, a standard CABG operation, through a median sternotomy and with the use of cardiopulmonary bypass, carries well recognised challenges. In this article, we describe newer approaches, such as off-pump CABG, minimally invasive bypass grafting, robotic CABG, and hybrid coronary revascularisation, which we consider as necessary ways to minimise invasion, reduce recovery time, provide the benefits of arterial grafting to more patients, and offer alternatives to mitigate the adverse effects of conventional sternotomy and cardiopulmonary bypass.
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Affiliation(s)
- Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Saurabh Gupta
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Menaka Ponnambalam
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun Yeong Chong
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Nakajima T, Iba Y, Shibata T, Ohkawa A, Kawaharada N. Identification of a Dissection Site in the Internal Thoracic Artery Using Fluorescence Imaging: A Case Report. Cureus 2024; 16:e55199. [PMID: 38558681 PMCID: PMC10980908 DOI: 10.7759/cureus.55199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
A 66-year-old man with a history of type 2 diabetes mellitus who was undergoing hemodialysis presented with angina. Coronary angiography revealed triple-vessel coronary artery disease. He underwent multiple percutaneous coronary interventions due to recurrent restenosis and was referred for coronary artery bypass grafting (CABG). The left internal thoracic artery and bilateral saphenous veins were harvested under general anesthesia. Four CABGs were performed: left internal thoracic artery to the left anterior descending artery; saphenous vein graft to the obtuse marginal branch of the circumflex artery; and saphenous vein graft to two sites in the right coronary artery. Intraoperative assessment with transit-time flow measurements showed no abnormalities, and the surgery was completed. On postoperative day seven, coronary and graft angiography revealed dissection of the left internal thoracic artery at its midportion with restricted flow. On postoperative day eight, a surgical intervention was performed to excise the dissected segment of the left internal thoracic artery. The dissection site was identified by fluorescence imaging. The dissected segment was excised, and the artery was re-anastomosed. The postoperative course was uneventful, and graft angiography performed on postoperative day 22 confirmed good blood flow. Fluorescence imaging was valuable in identifying the dissection site in the left internal thoracic artery.
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Affiliation(s)
| | - Yutaka Iba
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Tsuyoshi Shibata
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Akihito Ohkawa
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
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Thuan PQ, Chuong PTV, Nam NH, Dinh NH. Coronary Artery Bypass Surgery: Evidence-Based Practice. Cardiol Rev 2023:00045415-990000000-00183. [PMID: 38112423 DOI: 10.1097/crd.0000000000000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.
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Affiliation(s)
- Phan Quang Thuan
- From the Department of Adult Cardiovascular Surgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Pham Tran Viet Chuong
- From the Department of Adult Cardiovascular Surgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Nguyen Hoai Nam
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Nguyen Hoang Dinh
- From the Department of Adult Cardiovascular Surgery, University Medical Center, Ho Chi Minh City, Vietnam
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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Laali M, Bouchot O, Fouquet O, Maureira P, Verhoye JP, Corbi P, David CH, D'Alessandro C, Demondion P, Lebreton G, Leprince P. Analysis of a multicenter registry on evaluation of transit-time flow in coronary artery disease surgery. JTCVS OPEN 2023; 16:401-418. [PMID: 38204662 PMCID: PMC10775033 DOI: 10.1016/j.xjon.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 01/12/2024]
Abstract
Objective The Evaluation of Transit-Time Flow in Coronary Artery Disease Surgery (EFCAD) registry aims to assess the influence of transit-time flow measurement (TTFM) in daily practice. Methods EFCAD is a prospective, multicenter study involving 9 centers performing TTFM during isolated coronary artery bypass grafting. Primary end point was occurrence and risk factors of major adverse cardiac events, including perioperative myocardial infarction, urgent postoperative coronary angiogram and/or revascularization, and hospital mortality. Secondary end points were rate of graft revision during surgery and factors affecting graft flow. We respected the limit values set by the experts: mean graft flow >15 mL/minute and pulsatility index ≤5. Results Between May 2017 and March 2021, 1616 patients were registered in the EFCAD database. After review, 1414 were included for analyses. Of those, 1176 were eligible for primary end point analysis. Graft revision, mainly due to inadequate TTFM values, occurred in 2% (29 patients). The primary end point occurred in 46 (3.9%) patients, and it was related with left anterior descending artery graft flow ≤15 mL/minute (odds ratio, 3.64; P < .001). Graft flow was related with number of grafts (3 vs 1-2, β = -1.6; 4-6 vs 1-2, β = -4.1; P < .001; β > 0 indicates higher flow), and graft origin (aorta vs Y, β = 9.2; in situ left internal thoracic artery vs Y, β = 3.2; in situ right internal thoracic artery vs Y, β = 2.3; P < .001). Conclusions Data from EFCAD study suggest that TTFM is reliable to evaluate graft flow, and acceptance of inadequate flow on left anterior descending artery anastomosis influence postoperative outcomes. In our opinion, TTFM assessment should be routinely used in coronary artery bypass procedures, even if interpretation depends on learning curves.
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Affiliation(s)
- Mojgan Laali
- Thoracic and Cardiovascular Surgery Department, Sorbonne Université, APHP, Groupe hospitalier Pitié-Salpétrière, Institute of Cardiology, Paris, France
| | - Olivier Bouchot
- Cardio-Thoracic and Vascular Surgery Unit, Hospital Center University, Dijon, France
| | - Olivier Fouquet
- Cardiac Surgery, Angers University Hospital Center, Angers, France
| | - Pablo Maureira
- Cardiac Surgery Unit, Hospital Center, University de Nancy, Nancy, France
| | - Jean-Philippe Verhoye
- Thoracic and Cardiovascular Surgery Department, Hospital Center, University Rennes, Rennes, France
| | - Pierre Corbi
- Cardio-Thoracic and Vascular Surgery Unit, Hospital Center, University Poitiers, Poitiers, France
| | | | - Cosimo D'Alessandro
- Thoracic and Cardiovascular Surgery Department, Sorbonne Université, APHP, Groupe hospitalier Pitié-Salpétrière, Institute of Cardiology, Paris, France
| | - Pierre Demondion
- Thoracic and Cardiovascular Surgery Department, Sorbonne Université, APHP, Groupe hospitalier Pitié-Salpétrière, Institute of Cardiology, Paris, France
| | - Guillaume Lebreton
- Thoracic and Cardiovascular Surgery Department, Sorbonne Université, APHP, Groupe hospitalier Pitié-Salpétrière, Institute of Cardiology, Paris, France
| | - Pascal Leprince
- Thoracic and Cardiovascular Surgery Department, Sorbonne Université, APHP, Groupe hospitalier Pitié-Salpétrière, Institute of Cardiology, Paris, France
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12
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Ruel M. Designing the coronary artery bypass surgery operation of the future. Curr Opin Cardiol 2023; 38:490-495. [PMID: 37751390 DOI: 10.1097/hco.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW This article discusses current shortcomings in coronary artery bypass surgery and ways to overcome them. RECENT FINDINGS Minimally invasive coronary bypass surgery, robotic coronary bypass, and hybrid approaches aim to avoid sternotomy, employ arterial grafts, and minimize the use of cardiopulmonary bypass. Other considerations such as bypass graft validation, the optimization of guideline-directed medical therapy, and the development of coronary surgery specialists are also crucial to further the benefits of coronary artery bypass grafting on future patients. SUMMARY Coronary artery bypass grafting must become less invasive, be better validated, and be carried out with an even higher emphasis on quality, including graft validation and preoperative/postoperative optimization, if it is to remain the best treatment for advanced, severe coronary artery disease.
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Affiliation(s)
- Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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13
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Miazza J, Vasiloi I, Koechlin L, Gahl B, Santer D, Berdajs D, Nestelberger T, Kaiser C, Eckstein F, Reuthebuch O. Combining Minimally Invasive Direct Coronary Artery Bypass Grafting with Transapical Aortic Valve Implantation-The Next Level Heart Team Approach. J Clin Med 2023; 12:6890. [PMID: 37959355 PMCID: PMC10647604 DOI: 10.3390/jcm12216890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
We present the results of a combined approach for transapical aortic valve replacement and minimally invasive coronary artery bypass grafting (taTAVI-MIDCAB) in patients with combined aortic stenosis and coronary artery disease. BACKGROUND For patients presenting with aortic stenosis and coronary artery disease, a simultaneous procedure addressing both diseases is recommended to reduce operative risk. In high-risk patients with hostile femoral or coronary axis, taTAVI-MIDCAB can be an alternative minimally invasive approach, offering the benefits of left interior mammary artery to left anterior descending coronary artery (LIMA-LAD) grafting. METHODS From 2014 to 2022, 10 patients underwent taTAVI-MIDCAB for combined coronary and severe aortic stenosis in the hybrid operation theater at our institution. We assessed perioperative outcomes and follow-up outcomes. RESULTS The median age was 83 years (81 to 86). The procedure was successfully performed in all patients without conversion to sternotomy. The median length of hospital and intensive care unit stay was 9 days (7 to 16) and 2.5 days (1 to 5), respectively. The median flow over the coronary artery bypass was 31 (22 to 44) mL/min, with a pulsatility index (PI) of 2.4 (2.1 to 3.2). Mild paravalvular leak occurred in 2 patients (10%). There were no neurological events nor acute kidney injury. Pacemaker implantation was required in 1 patient (10%). CONCLUSIONS Simultaneous surgical coronary revascularization and interventional valve implantation in the setting of a hostile femoral and coronary axis appears to be safe and beneficial.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Thomas Nestelberger
- Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
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14
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Demirsoy E, Mavioglu I, Dogan E, Gulmez H, Dindar I, Erol MK. The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers. J Clin Med 2023; 12:5663. [PMID: 37685730 PMCID: PMC10488478 DOI: 10.3390/jcm12175663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVES Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease. METHODS It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy. RESULTS Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9. CONCLUSIONS Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.
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Affiliation(s)
- Ergun Demirsoy
- Division of Cardiovascular Surgery, Sisli Kolan International Hospital, Kaptanpaşa Mahellesi Darulaceze Caddesi No 14, Sisli, 34384 Istanbul, Turkey
| | - Ilhan Mavioglu
- Division of Cardiovascular Surgery, Private Practice, Sisli, 34394 Istanbul, Turkey;
| | - Emre Dogan
- Division of Cardiovascular Surgery, Sisli Kolan International Hospital, Kaptanpaşa Mahellesi Darulaceze Caddesi No 14, Sisli, 34384 Istanbul, Turkey
| | - Harun Gulmez
- Division of Cardiovascular Surgery, Sisli Kolan International Hospital, Kaptanpaşa Mahellesi Darulaceze Caddesi No 14, Sisli, 34384 Istanbul, Turkey
| | - Ismet Dindar
- Division of Cardiology, Sisli Kolan International Hospital, 34384 Istanbul, Turkey
| | - Mustafa Kemal Erol
- Division of Cardiology, Sisli Kolan International Hospital, 34384 Istanbul, Turkey
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15
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Crielaard H, Hoogewerf M, van Putte BP, van de Vosse FN, Vlachojannis GJ, Stecher D, Stijnen M, Doevendans PA. Evaluating the Arteriotomy Size of a New Sutureless Coronary Anastomosis Using a Finite Volume Approach. J Cardiovasc Transl Res 2023; 16:916-926. [PMID: 36943615 PMCID: PMC10480236 DOI: 10.1007/s12265-023-10367-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 02/27/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics. METHODS A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43 mm2; varied 0.94 - 3.6 mm2) and graft diameter (standard 2.5 mm; varied 1.5 - 5.0 mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR). RESULTS The current size ELANA (arteriotomy 1.43 mm2) presented an estimated FFR 0.65 (39 mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm2) surpassed the coronary cross-sectional area (2.69 mm2, i.e. 1.85 mm diameter), presenting an estimated FFR 0.75 (46 mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow. CONCLUSION The ratio between the required minimal coronary diameter for application and the ELANA arteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised.
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Affiliation(s)
- Hanneke Crielaard
- LifeTec Group, Eindhoven, The Netherlands
- Department of Cardiovascular Biomechanics, University of Eindhoven, Eindhoven, The Netherlands
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marieke Hoogewerf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - Bart P van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frans N van de Vosse
- Department of Cardiovascular Biomechanics, University of Eindhoven, Eindhoven, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - David Stecher
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
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16
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Gaudino M, Dangas GD, Angiolillo DJ, Brodt J, Chikwe J, DeAnda A, Hameed I, Rodgers ML, Sandner S, Sun LY, Yong CM. Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2023; 148:442-454. [PMID: 37345559 DOI: 10.1161/cir.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.
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17
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Ramponi F, Seco M, Vallely MP. Defining the Role of Anaortic Coronary Artery Bypass Grafting. J Clin Med 2023; 12:4697. [PMID: 37510812 PMCID: PMC10380961 DOI: 10.3390/jcm12144697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.
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Affiliation(s)
- Fabio Ramponi
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY 10025, USA
| | - Michael Seco
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney 2065, Australia
| | - Michael P Vallely
- Department of Cardiothoracic Surgery, Monash Health, The Victorian Heart Hospital, Melbourne 3168, Australia
- Department of Surgery, Monash University, Melbourne 3168, Australia
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18
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Hecker F, von Zeppelin M, Van Linden A, Scholtz JE, Fichtlscherer S, Hlavicka J, Walther T, Holubec T. Right-Sided Minimally Invasive Direct Coronary Artery Bypass: Clinical Experience and Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050907. [PMID: 37241139 DOI: 10.3390/medicina59050907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/29/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023]
Abstract
Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery to the left descending artery is a clinical routine in the treatment of coronary artery disease. Far less is known on right-sided MIDCAB (r-MIDCAB) using the right internal thoracic artery (RITA) to the right coronary artery (RCA). We aimed to present our experience in patients with complex coronary artery disease who underwent r-MIDCAB. Materials and Methods: Between October 2019 and January 2023, 11 patients received r-MIDCAB using RITA to RCA bypass in a minimally invasive technique via right anterior minithoracotomy without using a cardiopulmonary bypass. Underlying coronary disease was complex right coronary artery stenosis (n = 7) and anomalous right coronary artery (ARCA; n = 4). All procedure-related and outcome data were evaluated prospectively. Results: Successful minimally invasive revascularization was achieved in all patients (n = 11). There were no conversions to sternotomy and no re-explorations for bleeding. Furthermore, no myocardial infarction, no strokes, and, most importantly, no deaths were observed. During the follow-up period (median 24 months), all patients were alive and 90% were completely angina free. Two patients received a repeated revascularization after surgery but independently from the RITA-RCA bypass, which was fully competent in both patients. Conclusion: Right-sided MIDCAB can be performed safely and effectively in patients with expected technically challenging percutaneous coronary intervention of the RCA and in patients with ARCA. Mid-term results showed high freedom from angina in nearly all patients. Further studies with larger patient cohorts and more evidence are needed to provide the best revascularization strategy for patients suffering from isolated complex RCA stenosis and ARCA.
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Affiliation(s)
- Florian Hecker
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60598 Frankfurt, Germany
| | - Mascha von Zeppelin
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60598 Frankfurt, Germany
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60598 Frankfurt, Germany
| | - Jan-Erik Scholtz
- Department of Radiology, University Hospital Frankfurt and Goethe University Frankfurt, 60388 Frankfurt, Germany
| | - Stephan Fichtlscherer
- Department of Cardiology, University Hospital Frankfurt and Goethe University Frankfurt, 60388 Frankfurt, Germany
| | - Jan Hlavicka
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60598 Frankfurt, Germany
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60598 Frankfurt, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60598 Frankfurt, Germany
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19
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Quan Z, Zhang X, Song X, Chen P, Wu Q. The use of intraoperative transit time flow measurement can reduce postoperative myocardial injury. J Card Surg 2022; 37:4246-4253. [PMID: 35998272 DOI: 10.1111/jocs.16818] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/02/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study investigates the relationship between the use of transit time flow measurement (TTFM) and postoperative myocardial injury in off-pump coronary artery bypass grafting (OPCABG). METHODS In this retrospective study, we collected basic data from patients hospitalized for OPCABG in the Department of Cardiothoracic Surgery, Changzhou Second People's Hospital Affiliated with Nanjing Medical University. According to the academic research consortium (ARC)-2 definition of significant myocardial injury, we used cardiac troponin I >2380 ng/L as a criterion for significant postoperative myocardial injury. We use logistic regression and forest plots to assess the association of TTFM use with myocardial injury outcomes. RESULTS One hundred and forty-six patients were included in this study. The overall median age of these patients was 65.05 years, and 32 (21.92%) experienced a postoperative myocardial injury. TTFM was independently associated with the incidence of postoperative myocardial injury (odds ratio = 0.34 [95% confidence interval = 0.15-0.78]; p = .01), and we found similar trends in regression analyses across subgroups of sex, age, number of bridging vessels, hypertension, diabetes mellitus, BMI, and percutaneous coronary revascularization. One hundred and six patients were followed for 1-year vessel permeability, and seven patients (6.6%) were occluded. CONCLUSIONS The use of TTFM is independently associated with a reduced incidence of postoperative myocardial lesions during off-pump coronary bypass surgery. The TTFM procedure in OPCABG deserves to be actively promoted to reduce the incidence of postoperative myocardial injury.
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Affiliation(s)
- Zheng Quan
- Department of Thoracic and Cardiovascular Surgery, Affiliated with Nanjing Medical University, Changzhou, Jiangsu, China.,Department of Thoracic and Cardiovascular Surgery, Dalian Medical University, Dalian, Liaoning, China
| | - Xiaoyu Zhang
- Heart Center, Northwest Women and Children's Hospital, Xi'an, Shaanxi, China
| | - Xueyu Song
- Department of Thoracic and Cardiovascular Surgery, Affiliated with Nanjing Medical University, Changzhou, Jiangsu, China.,Department of Thoracic and Cardiovascular Surgery, Dalian Medical University, Dalian, Liaoning, China
| | - Pengyu Chen
- Department of Thoracic and Cardiovascular Surgery, Affiliated with Nanjing Medical University, Changzhou, Jiangsu, China.,Department of Thoracic and Cardiovascular Surgery, Dalian Medical University, Dalian, Liaoning, China
| | - Qiyong Wu
- Department of Thoracic and Cardiovascular Surgery, Affiliated with Nanjing Medical University, Changzhou, Jiangsu, China
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20
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Benetti F. The use of intraoperative transit time flow measurement can reduce preoperative myocardial injury. J Card Surg 2022; 37:4254-4255. [PMID: 36124406 DOI: 10.1111/jocs.16814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Federico Benetti
- Department of Cardiac Surgery, Benetti Foundation, Rosario, Argentina
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21
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Mavioglu I, Vallely MP. Minimally invasive off-pump anaortic coronary artery bypass (MACAB). J Card Surg 2022; 37:4944-4951. [PMID: 36378893 DOI: 10.1111/jocs.17180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Minimally invasive direct coronary artery bypass has enabled coronary artery bypass graft to compete with the appeal of less invasive percutaneous coronary procedures. Favorable results of coronary artery bypass surgery performed without the use of cardiopulmonary bypass and without touching the aorta (anOPCAB) have enabled the development and use of minimally invasive methods. METHODS Between 2016 and 2021, 112 patients underwent multivessel coronary bypass surgery performed using a minimally invasive method through a small thoracotomy in the left chest with off-pump, anaortic, and all-arterial grafts (Minimally Invasive Off-Pump Anaortic Coronary Artery Bypass [MACAB]). Patient data were collected and retrospectively analyzed. Eight series from the literature using the multivessel mini-OPCAB and MACAB technique were also evaluated. RESULTS Collectively, from the literature, 2729 patients underwent an average of 2.4 bypasses with an early mortality rate of 0.7% and a stroke rate of 0.16%. In our MACAB case series, 112 patients underwent an average of 2.9 bypasses with a mortality rate of 1.8% and a stroke rate of 0%. CONCLUSION MACAB can be performed safely by experienced surgeons and reduces neurological injury and surgical trauma and may be a good alternative for multivessel stenting. Simulation systems are essential for its dissemination, and teams dedicated to coronary surgery-with subspecialty expertise-are necessary to achieve good outcomes.
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Affiliation(s)
- Ilhan Mavioglu
- Cardiovascular Surgery, Cardiac Surgical Clinic of Private Cardiac Surgeons, Istanbul, Turkey
| | - Michael P Vallely
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, New York, USA
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22
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Armstrong PW, Bates ER, Gaudino M. Left main coronary disease: evolving management concepts. Eur Heart J 2022; 43:4635-4643. [PMID: 36173870 DOI: 10.1093/eurheartj/ehac542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023] Open
Abstract
Remarkable advances in the management of coronary artery disease have enhanced our approach to left main coronary artery (LMCA) disease. The traditional role of coronary artery bypass graft surgery has been challenged by the less invasive percutaneous coronary interventional approach. Additionally, major strides in optimal medical therapy now provide a rich menu of treatment choices in selected circumstances. Although a LMCA stenosis >70% is an acceptable threshold for revascularization, those patients with a LMCA narrowing between 40 and 69% present a more complex scenario. This review examines the relative merits of the different treatment options, addresses key diagnostic and therapeutic unknowns, and identifies future work likely to advance progress.
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Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, 4-120 Katz Group Centre for Pharmacy and Health Research, Edmonton, AB T6G 2E1, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-111 St., Edmonton, AB T6G 2B7, Canada
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive 2139 Cardiovascular Center, Ann Arbor, MI 48109, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th St, Box 110, New York, NY 10065, USA
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23
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Jiritano F, Leone A, Greco F, Leporace M, Bova C, Aiello V, Serraino GF, Mastroroberto P. Transit time flow measurement guiding the surgical treatment for anomalous origin of the right coronary artery: A case report. Front Cardiovasc Med 2022; 9:975014. [PMID: 36337901 PMCID: PMC9632949 DOI: 10.3389/fcvm.2022.975014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/30/2022] [Indexed: 11/27/2022] Open
Abstract
Anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) in symptomatic patients is a rare but serious finding whose treatment consists of a surgical correction. The surgical treatment has a level of complexity that could vary from unroofing and ostioplasty to coronary artery bypass grafting. We present our management of a 59-year-old woman presenting with chest pain and dyspnea for right ACAOS with an interarterial route. The right coronary artery (RCA) was bypassed with the right internal thoracic artery. An intraoperative transit time flowmetry (TTFM) showed a competitive flow from the native RCA. RCA proximal ligation site was identified intraoperatively, considering the best mean graft flow (MGF) and the absence of ischemic events. The patient was discharged after a week without adverse events. The 1-year follow-up was uneventful. The intraoperative use of TTFM could guide the surgeon's hand making straightforward the surgical treatment for ACAOS.
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Affiliation(s)
- Federica Jiritano
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
| | - Angelo Leone
- Cath Lab Unit, Azienda Ospedaliera Santissima Annunziata Hospital, Cosenza, Italy
| | - Francesco Greco
- Cath Lab Unit, Azienda Ospedaliera Santissima Annunziata Hospital, Cosenza, Italy
| | - Mario Leporace
- Radiology Unit, Azienda Ospedaliera Santissima Annunziata Hospital, Cosenza, Italy
| | - Carlo Bova
- Medical Unit, Azienda Ospedaliera Santissima Annunziata Hospital, Cosenza, Italy
| | - Vincenzo Aiello
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, Catanzaro, Italy
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24
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Zhou Z, Fu G, Feng K, Huang S, Chen G, Liang M, Wu Z. Randomized evidence on graft patency after off-pump versus on-pump coronary artery bypass grafting: An updated meta-analysis. Int J Surg 2022; 98:106212. [PMID: 35041977 DOI: 10.1016/j.ijsu.2021.106212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The debate between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) has been ongoing for decades. We aimed to provide a comprehensive update of the current randomized controlled trials (RCTs) in evaluating the graft patency of OPCAB versus ONCAB. MATERIALS AND METHODS A literature search was conducted in PubMed, EMBASE, and the Cochrane Library databases until April 30, 2021. All RCTs from 2003 to 2020 comparing the results of graft patency between OPCAB and ONCAB were included. We compared the overall graft occlusion between the two groups, and subgroup analyses were conducted based on different types of conduits and target territories, crossover from off-pump to on-pump rate, and the length of follow-up. RESULTS Sixteen RCTs were identified, with 5743 grafts in the OPCAB group and 5898 in the ONCAB group. OPCAB was associated with a higher risk of occlusion in the overall graft (RR: 1.31; 95% CI, 1.17-1.46), saphenous vein graft (SVG) (RR: 1.40; 95% CI, 1.23-1.59), grafts to left anterior descending (LAD) territory (RR: 1.52; 95% CI, 1.11-2.08) and left circumflex artery (LCX) territory (RR: 1.45; 95% CI, 1.19-1.76), while no significant difference was observed between the two groups in respect of arterial conduits and grafts to right coronary artery (RCA) territory. Furthermore, the lower crossover rate and longer length of follow-up appeared to reduce the association between OPCAB and lower graft patency. CONCLUSIONS The current meta-analysis indicates that, compared with ONCAB, graft patency is poorer with OPCAB for overall grafts, SVG grafts, grafts to LAD and LCX territories, whereas the results remain comparable for arterial conduits and grafts to RCA territory.
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Affiliation(s)
- Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
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Buchko MT, Ruel M. Commentary: The saphenous vein in coronary artery bypass grafting: Optimizing our workhorse. JTCVS Tech 2021; 10:110-111. [PMID: 34984369 PMCID: PMC8691916 DOI: 10.1016/j.xjtc.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Max T. Buchko
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
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Ruel M. Nonsternotomy multivessel coronary artery bypass grafting: A key development in cardiac surgery. JTCVS Tech 2021; 10:162-167. [PMID: 34977721 PMCID: PMC8691821 DOI: 10.1016/j.xjtc.2021.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/16/2021] [Indexed: 11/11/2022] Open
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