Can Minimally Invasive Multivessel Coronary Revascularization Be a Routine Approach?

BACKGROUND

Advancement in the field of cardiovascular surgery has emerged with various minimally invasive approaches for the treatment of multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. This study describes our routine technical approach and clinical experience of minimally invasive coronary artery bypass via left anterior minithoracotomy for the treatment of patients with multivessel coronary lesions.

METHODS

Our experience includes 100 consecutive patients who were operated between July 2020 and April 2021. The left internal thoracic artery was harvested in all patients. Radial arterial grafts and saphenous vein grafts were harvested endoscopically. Patients were operated either under cardiopulmonary bypass (CPB) with blood cardioplegia through left anterior minithoracotomy of 5 to 7 cm or off-pump via left anterolateral minithoracotomy.

RESULTS

We had single mortality (1%), no early postoperative myocardial infarction was observed. None of our patients was converted to sternotomy (0%). The mean number of bypass was 3.1 ± 0.8, the mean cross-clamping time was 78.1 ± 20.6 minutes, the mean CPB time was 153.2 ± 37.5 minutes, the average intubation time was 6.33 ± 11.29 hours, the mean intensive care unit stay was 1.62 ± 1.78 days, the mean hospital stay was 4.98 ± 3.01 days, the average total operation time was 4.20 ± 0.92 hours, and the average pleural drain was 393.8 ± 169.7 mL.

CONCLUSION

Minimally invasive coronary artery bypass grafting via left anterior minithoracotomy can be routinely performed with safety and it is feasible, reproducible with a short learning curve. Further multicenter studies are needed for the standardization of our technique.

Trace Element Status and Postoperative Morbidity After On-pump Coronary Artery Bypass Surgery

Trace elements are essential micronutrients that take part in most antioxidant reactions in the body. In this study, we evaluated the levels of copper, chromium, manganese, selenium, magnesium, zinc, iron, and silicon in adult patients who undergone isolated on-pump coronary artery bypass with the occurrence of postoperative atrial fibrillation, transient renal injury, transient liver injury, and rate of wound infection; 51 adult patients (41 men, 10 women) underwent isolated coronary artery bypass grafting (CABG) under cardiopulmonary bypass. The mean age was 61,9 ± 8,0 years (range 45-82 years). Blood samples were collected preoperatively, postoperative first hour, postoperative first day, and fifth postoperative day for element analysis. Serum levels were determined by an Inductive Coupled Plasma Optical Emission Spectrometer (ICAP 6000). Serum copper, zinc, and selenium values, typically known as strong antioxidant elements in the body, decreased significantly during the first hour and first day of postoperative period compared to the preoperative period (p < 0.05). Also, postoperative atrial fibrillation, transient renal injury, transient liver injury, and rate of wound infection were observed to increase with the decrease in levels of trace elements (p < 0.05). The levels of these elements were observed to return to normal levels during the fifth postoperative day. The levels of trace elements decrease significantly after on-pump coronary artery bypass surgery. Our study results suggest that this could be one of the predisposing factors for increased postoperative atrial fibrillation, transient kidney injury, transient renal injury, and increased rate of wound infections for patients undergoing on-pump coronary artery bypass grafting.

UNILATERAL ANTEGRADE CEREBRAL PERFUSION VERSUS DEEP HYPOTHERMIC CIRCULATORY ARREST DURING ACUTE AORTIC DISSECTION REPAIR: A SINGLE CENTER EXPERIENCE

Introduction

The gold standard of circulation strategy and arterial cannulation during acute aortic dissection is still indisputable. Unilateral/bilateral antegrade cerebral perfusion (UACP/BACP) and deep hypothermic circulatory arrest (HCA) remains a safe and useful procedure for circulation during management of acute aortic dissection. The aim of our study was to investigate the effectiveness of both unilateral antegrade cerebral perfusion and deep hypothermic circulatory arrest on postoperative outcomes during management of acute aortic dissection repair at our center.

Methods

Our prospective study consisted of 26 patients who underwent acute aortic dissection repair with various circulation strategy. Group A consisted of 14 (53.8%) patients who were operated on under unilateral antegrade cerebral perfusion, while group B consisted of 12 (46.2%) patients who were operated on under deep hypothermic circulatory arrest without cerebral perfusion. Postoperative outcomes included mortality, drainage, blood transfusion (free frozen plasma, erythrocyte suspension), ventilation time and revision due to bleeding.

Results

The average age of our study population was 55.2 ± 16.2 (range 33-83) years. Mortality was observed in 3 (11.5%) of our patients. There was no significant difference between the groups in terms of mortality and revision due to bleeding (p ˃ 0.05). Blood transfusion (erythrocyte suspension and free frozen plasma), drainage and ventilation time were significantly lower in Group A compared with Group B (p ˃ 0.05).

Conclusion

Both unilateral antegrade cerebral circulation and deep hypothermic circulatory arrest can be safely used during acute aortic dissection, although unilateral antegrade cerebral circulation has proved to be superior over deep hypothermic circulatory arrest with good postoperative outcomes.

Minimal invasive approach of post-MI ventricular septal defect repair and coronary artery revascularization via left anterior minithoracotomy

A 54-year-old male was admitted to our hospital with a prolonged dypsnea, orthopnoea, and chest pain that has lasted for almost 2 weeks. Physical examination revealed symptoms of heart failure. Transthoracic echocardiography revealed a ventricular septal defect located at the apical segment of the interventricular septum, mild mitral regurgitation, and hypokinesia of the apex of the left ventricle. Coronary angiography showed a critical proximal lesion of the left anterior descending artery. He was diagnosed with postmyocardial infarction ventricular septal defect. Our patient underwent minimal invasive coronary artery bypass and ventricular septal defect repair via left anterior minithoracotomy. Postoperative period was uneventful and our patient was released on a postoperative Day 7. Postoperative transthoracic echocardiography revealed no residue of repaired ventricular septal defect with improved left ventricular functions.

Strategies and pitfalls during minimally invasive total coronary artery revascularization via left anterior minithoracotomy: a promising future

For many years up to date coronary artery bypass surgery has been performed via sternotomy as a gold standard approach. However recently there has been alternative approaches for coronary artery bypass grafting in minimal invasive ways to reduce complications associated with sternotomy such as sternal wound infections, impared pulmonary functions and cosmetic related problems. Most of these minimal invasive procedures have been associated with long learning curve, high costs and sophiscated instruments used during surgery. Minimal invasive coronary artery bypass grafting via left anterior mini-thoracotomy is equally effective as a gold standard sternotomy with the same principles of suturing techniques and provides a great comfort in many aspects as sternotomy. It is safe and does not require sophiscated tools which require long learning curve and high expanses. This type of surgery requires the use of novel strategies, especially in patients who hold the highest potential for postoperative morbidity. In this paper, we will highlight the strategies and pitfalls associated with minimally invasive total coronary revascularization via left anterior minithoracotomy.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement

OBJECTIVE

Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses.

METHODS

In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared.

RESULTS

Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and crossclamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220).

CONCLUSIONS

Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Do all type 2 aortic dissection require emergency surgery?

We represent a case of asymptomatic isolated chronic ascending aortic dissection that lasted for 15 years in which a patient was only followed up with medical therapy that saved him from early surgical intervention.

Staged or Combined Approach for Carotid Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting: A 5-Year-Long Experience

Background: Optimal surgical approach for patients with hemodynamically significant carotid and coronary disease remains controversial. We analyzed our 5-year experience and compared early and long-term outcome following staged and combined carotid and coronary artery bypass. Methods: 312 consecutive patients undergoing carotid endarterectomy and coronary artery bypass between 2008 and 2013 were prospectively enrolled in the study. Patients were scheduled for a staged (carotid endarterectomy followed by coronary artery bypass within 1 week) procedure (Group S) unless they were unstable in terms of cardiac status (were deemed to a combined procedure; Group C). All patient data including demographics, risk factors, immediate perioperative events, 30-day, and long-term outcome were prospectively recorded and then analyzed. Groups S and C were compared for pre- and perioperative data as well as immediate, 30-day, and long-term survival. A P value less than .05 was considered significant. Survival analysis was made using Kaplan-Meier method and log-rank test.Results: Group S included 204 patients and Group C included 108 patients. Preoperative demographics and clinical data were similar in the two groups except that preoperative cerebrovascular events were more common in Group C (31.7% versus 22.22%, P = .036) and bilateral carotid disease was more common in Group S. The EuroSCORE was higher in Group C (2.91 versus 2.65, P = .013). Carotid surgery techniques were similar; intraluminal shunting was more frequent in group C than group S (33.33% versus 9.88%, P = .001). Additional cardiac procedures in addition to coronary surgery was predominant in Group C. 30-day neurological adverse event rates, ICU, and hospital stay were significantly higher in Group C. The 30-day mortality was also sigficantly higher in Group C (1.96% versus 4.62%, P = .001). Conclusion: Staged and combined surgical approaches yield comparable outcomes. A staged approach may provide a more favorable neurological outcome with significantly reduced need for intraluminal shunting. Long-term outcome is, however, similar.

Off-Pump Double Coronary Bypass in a Case of Familial Hypercholesterolemia With Coarctation of the Aorta

Familial hypercholesterolemia is an uncommon disease that may be associated with atherosclerosis affecting coronary arteries and the ascending aorta. Coarctation of the aorta is rarely involved in this disease. The ideal surgical approach for management of coexisting coronary artery disease and coarctation of the aorta in a child with familial hypercholesterolemia is unclear. We report the case of a 14-year-old girl with familial hypercholesterolemia who underwent double coronary artery bypass grafting due to proximal lesions of both the left anterior descending artery and the right coronary artery.

Effect of Proximal Anastomotic Diameter on Venous Bypass Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting

BACKGROUND

In this study, the relationship between patency of saphenous vein (SV) graft and different sizes of aorta wall punches was investigated during the follow-up period after coronary artery bypass graft surgery. We also evaluated the other possible factors affecting SV graft patency.

METHODS

This study consisted of 266 consecutive and symptomatic patients with postoperative angiography. The primary endpoint was at least one saphenous graft failure observed from coronary computed tomography angiography (cCTA) and/or invasive angiography after surgery. Groups were created as SV occluded and patent group. Survival curves of patients in groups were estimated using Kaplan-Meier method and compared by log-rank test. Multivariate analysis was performed using the Cox proportional hazard model.

RESULTS

Cox-regression analysis demonstrated influence of older age (P = .023) and Diabetes Mellitus (DM) (P = .002) on SV graft failure. However, increasing ejection fraction (P = .011) was a protective factor against SV graft failure. There was no significant difference between the two groups in terms of usage rate of the punches with different diameters (P = .296).

CONCLUSION

The incidence of SV graft patency does not seem to increase in patients whose 4.8-mm aortic punch was used during proximal anastomosis compared to the reference group in which a punch of 4.0 mm was used. Also, the final proximal anastomosis graft size that was measured using cCTA was similar between patients with 4.8-mm punch and patients with 4-mm punch. Results from this study could help to determine which size for aortosaphenous anastomosis is clinically optimal.

Impact of the total pericardial closure using bilateral trap door incision and pericardial cavity intervention on outcomes following coronary artery bypass grafting: a randomized, controlled, parallel-group prospective study

OBJECTIVES

In this randomized, controlled and parallel-group prospective study, the feasibility of total pericardial closure with an intrapericardial drain and a pericardio-pleural window (pericardial cavity intervention) was investigated by examining postoperative outcomes, including atrial fibrillation and pericardial effusion, following coronary artery surgery.

METHODS

Cases were classified into two groups using a random procedure: the closure group and the open group. Insertion of an intrapericardial drain along the right atrium, pericardio-pleural window and total closure of the pericardium were performed in patients in the closure group. Partial closure of the pericardium was performed in patients in the open group. A straight semi-rigid drain was inserted into the extrapericardial anterior mediastinum and a right angle drain was inserted into the left chest in all patients. The primary endpoint was to evaluate the impact of surgical technique on the rate of postoperative in-hospital atrial fibrillation in the closure group. The secondary endpoint was to evaluate the relationship between the surgical technique and postoperative amount of pericardial effusion.

RESULTS

A total of 142 isolated, on-pump cases were examined: 72 in the open group and 70 in the closure group. Postoperative atrial fibrillation occurred in 27.78% of the cases in the open group and 8.57% of the patients in the closure group (P = 0.003). Another statistically significant outcome was the lower incidence of small pericardial effusion in the patient group with a closed pericardium during the second day of postoperative care (P = 0.039). The length of both critical care unit (P = 0.008) and hospital stay (P = 0.047) were also significantly shorter in the patient group with a closed pericardium.

CONCLUSIONS

Total pericardiorrhaphy with pericardial cavity intervention can be acceptable and favourable in terms of its outcomes, including reducing incidence of postoperative atrial fibrillation, pericardial effusion and length of hospitalization.

Impact of Coronary Artery Anatomy in Arterial Switch Procedure on Early Mortality and Morbidity

OBJECTIVE

Arterial switch operation has become the treatment of choice for neonates with transposition of the great arteries. The most important step of the procedure is transferring the coronary arteries to the neoaorta successfully. This study shows the impact of coronary anatomy on early mortality and morbidity after arterial switch operation.

METHODS

Ninety-two patients with transposition of the great arteries who underwent arterial switch operation between October 2010 and September 2014 were included in this retrospective study. The patients were classified into two groups: group I (n = 68, patients with usual coronary artery anatomy) and group II (n = 24, patients with unusual coronary artery anatomy). Median age was 10 days (6-25 days) in group I and 14 days (7-29 days) in group II. In group I, 25 patients had ventricular septal defect, nine patients had coarctation of the aorta or distal aortic arch hypoplasia, seven patients had Taussig Bing anomaly. In group II, nine patients had ventricular septal defect, one patient had coarctation of aorta, and one patient had Taussig Bing anomaly.

RESULTS

Regarding the postoperative variables, no significant statistical difference was found between two groups. But cardiopulmonary bypass time is significantly longer in group II (P = .004). There was no difference in complications including the mortality (P = .265). It is statistically found that associated anomalies did not affect the mortality and complication rates. All mortality cases (n = 4) were related to ventricular dysfunction in group II, whereas only four of the eight patients died because of ventricular dysfunction in group I.

CONCLUSION

Coronary artery pattern was not a predictor of mortality in early postoperative period. There may be an impact of unusual coronary artery pattern on the development of ventricular dysfunction as a cause of mortality.

The Preventive Effects of Posterior Pericardiotomy with Intrapericardial Tube on the Development of Pericardial Effusion, Atrial Fibrillation, and Acute Kidney Injury after Coronary Artery Surgery: A Prospective, Randomized, Controlled Trial

BACKGROUND

 Pericardial effusion (PE), atrial fibrillation (AF), and acute kidney injury (AKI) are commonly found after coronary artery surgery. These adverse events may also be interwoven in the postoperative period. In this prospective study, we investigated whether posterior pericardiotomy (PP) with intrapericardial tube positioned along the right atrium (pericardial space intervention) is effective in the prevention of these adverse events.

METHODS

 The patients were randomly distributed to the study and control groups. The study group consisted of patients with pericardial space intervention, whereas the control group consisted of patients without pericardial space interventions. In all patients, a straight tube was placed in the anterior mediastinum and an angled tube was placed into the left hemithorax.

RESULTS

 A total of 210 patients were studied: 107 in the control group and 103 in the study group. Statistically significant results were obtained in the amount of PE, cardiac tamponade, AF (p = 0.019), and AKI during the postoperative period, in favor of the study group. Length of hospital stay was significantly shorter in the study group (6.11 ± 2.31, p = 0.009).

CONCLUSION

 The PP with intrapericardial tube approach is safe, easy, and effective in the prevention of PE, cardiac tamponade, and AF. The use of this approach may reduce the risk of developing AKI during the postoperative period. Besides, this technique also reduces the length of hospital stay.