Faculty Bibliography

Total arterial myocardial revascularization (TAMR) is advisable because of the excellent long-term patency of arterial conduits. We present early and midterm outcomes of five different surgical configurations for TAMR. Between January 1998 and May 2004, 112 patients (aged 56.5 +/- 4.5 years, 20% female) with three-vessel disease underwent TAMR. The internal mammary arteries (IMAs) were harvested in a sketelonized fashion. The surgical techniques for TAMR consisted in Y or T composite grafts (n = 88, 78%) constructed between the in situ right IMA (RIMA) and the free left IMA (LIMA) graft (n = 58) or the radial artery (n = 30) (RA) in three different configurations. The other techniques consisted in T- and inverted T-graft (n = 24, 22%) constructed between the RA conduit and the free LIMA graft in two different configurations. The mean follow-up time was 40 +/- 23 months. Postoperative angiographic control was performed in 76/111 (70%) patients. Overall, 472 arterial anastomoses (average 4.2 per patient) were performed. One (0.9%) patient, undergoing the inverted T-graft technique, died on postoperative day 2. Another patient (0.9%), undergoing the lambda-graft technique using both IMAs and RA, suffered a new myocardial infarction probably due to RA conduit vasospasm. One week after surgery, after the transthoracic echocardiographic Doppler with adenosine provocative test, the coronary flow reserve (CFR) at the LIMA and RIMA main stems were 2 +/- 0.4 and 2.4 +/- 0.3, respectively. At 12-month follow-up, after adenosine provocative test, the CFRs at the LIMA and RIMA stems were significantly higher than the values at 1 week after surgery within the same group; (LIMA)CFR (1 week) 2.4 +/- 0.3 (12 months) vs 2 +/- 04 (1 week), P = 0.002; (RIMA)CFR 2.58 +/- 0.4 vs 2.4 +/- 0.3, P = 0.001. The CFR at the RIMA main stem was higher in all measurements within the same group than in the LIMA main stem, but not significantly. In one patient undergoing the lambda-graft technique using both IMAs, the RIMA was found to have a string sign. Postoperative angiography in 50 patients showed that the patency rate for the LIMA was 100%, for the RIMA 97.3%, and for the RA 96.7%. Angiography at 3-year follow-up in 76 patients documented excellent patency rates of the LIMA (97.4%), RIMA (95%), and RA (87%). Survival at 7 years was 92.5%, event-free survival 89.3%, and freedom from angina 94%. Total arterial myocardial revascularization using different surgical configurations is safe and effective. The use of composite arterial grafts provides excellent clinical and angiographic results, with a low rate of angina recurrence and late cardiac events. These configurations allow for complete arterial revascularization.

OBJECTIVES/OBJECTIVE:The aims of this study were to (1) compare the release of S-100 beta and NSE in off-pump coronary artery bypass grafting (CABG) versus on-pump surgery; (2) investigate whether the S-100 beta and NSE serum concentrations correlate with cardiopulmonary bypass (CPB) duration. MATERIALS AND METHODS/METHODS:Between October 2002 and May 2004, 42 patients undergoing first time CABG surgery were enrolled in the study. The exclusion criteria were: LVEF<35%, age>70 years, previous myocardial infarction, REDO surgery, the presence of valvular heart disease and/or cerebrovascular disease, abnormal preoperative carotid vessels angiography, coronary artery disease involving the distal circumflex artery, renal dysfunction, coagulopathy. The patients were randomly assigned either to undergo on-pump CABG surgery [group I, n=24 patients] or off-pump CABG [group II, n=18 patients]. Blood was not re-transfused from the cardiotomy suction. All patients presenting haemolysis were excluded from the study. RESULTS:The preoperative S-100beta was 0.13+/-0.08 (microg/l) and NSE 7+/-1.5 (microg/l) in group I and 0.12+/-0.1 (microg/l) and 6.9+/-2.7 (microg/l), respectively in group II. Six hours after the surgery, S-100beta in patients of group I reached a maximum level of 1.38+/-0.4 (microg/l) and NSE of 17.7+/-6.5 (microg/l) compared to 0.5+/-0.11 (microg/l) [S-100B] and NSE 8.6+/-4.2 (microg/l) in group II (p=0.001). Three (12%) patients in group I and none (0%) in group II suffered postoperative delirium, p=0.247. No strokes occurred linear regression analysis revealed a strong correlation between cardiopulmonary bypass duration and S-100beta and NSE peak levels, p<0.0021 (r(2)=0.36) and p<0.0001 (r=0.81), respectively. CONCLUSION/CONCLUSIONS:Coronary artery bypass surgery with CPB causes a significantly greater increase in NSE and S-100beta serum levels than off-pump surgery and correlates with CPB duration.

OBJECTIVE:Ventricular assist device (VAD) placement after postcardiotomy failure is associated with a high mortality. We sought to determine prognostic factors in order to help better select patients who may benefit from VAD placement. METHODS:From January 1992 to January 2003, 63 patients out of approximately 30,000 cardiac surgery patients (0.21%) developed postcardiotomy failure requiring VADs. Planned VAD for bridge to transplant or bridge to recovery were excluded. Multivariate logistic regression analysis, based on pre-VAD placement parameters, was used to determine prognostic factors for in-hospital 30-day mortality. RESULTS:Overall operative mortality was 73% (46 of 63). Multivariate logistic regression analysis identified median age </=50 (each additional year) (OR = 0.85, 95% CI = 0.77 to 0.95, p = 0.004) and median base deficit >/=0 mEq/L (each additional mEq/L) prior to VAD placement (OR = 0.60, 95% CI = 0.48 to 0.91, p = 0.012) to be independent predictors of improved 30-day survival. CONCLUSIONS:Postcardiotomy failure is a rare event but is associated with a very poor prognosis despite salvage therapies utilizing VADs. Age </=50 years and base deficit >/=0 (mEq/L) prior to VAD placement are associated with improved 30-day survival.

AIM/OBJECTIVE:In patients with unstable angina (UA) undergoing nonelective myocardial revascularization we compare the outcomes of skeletonized bilateral internal mammary arteries (BIMA) vs left internal mammary artery (LIMA) and saphenous vein grafts (SVGs) vs SVGs only. METHODS:Between January 1997 and December 2003, 758 patients: 612 (80.7%) males, mean age 62+/-12 years, underwent nonelective coronary artery bypass grafting (CABG) for unstable angina; 205 (27%) were operated emergently and 553 (73%) urgently. BIMA were employed in 320 (42%) patients (Group B) , isolated LIMA and/or SVGs in 332 (44%) patients (Group M) and only SVGs in 106 (14%) (Group S). RESULTS:In-hospital mortality (B=5.9%, M=4.5% and S=7.5%), and perioperative myocardial infarction (B=2.2%; M=1.9%, S=3.7%) were similar between the 3 groups (P=NS). Actuarial survival at 1, 3 and 7 years was 98.7%, 97.5% and 96.2% in group B, 99.3%, 94.8% and 89.4% in group M (P< 0.057 at 7 years follow-up) and 98%, 93.2% and 84.3% in group S (P=0.001). At 7 years follow-up, the event-free cardiac survival (92% vs 89.1%, P=0.045), angina-free survival (98.6% vs 95.8%, P=0.056), reoperation-free cardiac survival (98% vs 96%, P= 0.05) and infarct-free cardiac survival (98.7% vs 96.9%, P=0.062) showed a consistent trend to be superior in group B. Multivariate analysis identified age >65 years (P= 0.02), left ventricular ejection fraction (LVEF) <35% (P= 0.01), >1 ischemic irreversible area (P= 0.03) as independent predictors for late deaths, while the use of the LIMA (P= 0.006) and both mammary arteries (P= 0.001) decreased the risk of late deaths. CONCLUSIONS:The use of BIMA in nonelective CABG for UA is safe and effective. There is a trend, however, toward a survival benefit with improved freedom from late cardiac events (recurrence of angina, freedom from reoperation and infarction).

BACKGROUND:We sought to develop and internally validate a prediction score for all-cause in-hospital mortality in patients who have acute renal failure and require renal replacement therapy after cardiac surgery. METHODS:From January 1992 to July 2001, 136 of 14,000 patients (0.9%) had acute renal failure requiring renal replacement therapy after cardiac surgery. Multivariate logistic regression analysis, based on pre-renal replacement therapy variables, was used to construct a predictive score for all causes of in-hospital mortality. Subsequently, the score was validated in 27 patients who underwent surgery between August 2001 and March 2003. RESULTS:In-hospital mortality was 58% (79 of 136). From the logistic regression model, we assigned a score (range, 0 to 6) based on the presence of independent predictors of operative mortality (preoperative creatinine < or = 1.5 mg/dL [odds ratio (OR) = 5.0], hypertension [OR = 4.4], predialysis coma [OR = 9.6], sepsis [OR = 6.4], and total bilirubin > or = 2 mg/dL [OR = 5.6]). Higher scores strongly predicted mortality: patients who scored 3 or higher before the initiation dialysis (n = 54), had a mortality rate of 94% (51 of 54). In contrast, patients who scored 1 or less on this scale (n = 36), had a mortality of 16% (6 of 36). In the validation cohort, the sensitivity of the new score at the cutoff of 2 or fewer points versus 3 or more points was 0.71, the specificity was 0.90, the positive predictive value was 0.92, and the negative predictive value was 0.64. CONCLUSIONS:The prediction score represents a simple and accurate tool for predicting in-hospital mortality associated with renal replacement therapy for cardiac surgery patients before the institution of this resource-intensive treatment.

Mitral valve regurgitation (MVR), occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction, predicts a poor outcome in terms of survival and morbidity. Between 1995 and 2003, 180 consecutive patients with impaired LV function and chronic ischemic MVR underwent cardiac surgery. Fifty-four patients (group I), MVR (grade III-IV) underwent simultaneous MV surgery and coronary artery bypass grafting (CABG); 40 patients (group II), MVR (grade II-III), and 86 patients (group III), MVR (grade I-II), underwent CABG alone. In group I, MV repair was performed in 36 patients (group IA) and MV replacement in 18 (group IB). The incidence of hospital death was similar between groups. The actuarial event-free survival was significantly lower in group than in groups II and III (P = 0.0045) and I (P = 0.038). The overall actuarial survival was significantly higher in group IA than in group IB (P = 0.027). Postoperatively, the LV ejection fraction (P < 0.001), LV end-diastolic diameter (P < 0.001), LV end-systolic diameter (P < 0.01), and cardiac index (P < 0.001) improved significantly in group I. The regurgitation fraction decreased significantly in Groups I and III after surgery (P < 0.001 and P = 0.003, respectively). Both MV repair and replacement that preserves subvalvular apparatus in patients with end-stage ischemic myocardiopathy offer an acceptable outcome. Mitral valve repair simultaneous to CABG improves significantly the LV function and its geometry. In patients with mild to moderate mitral regurgitation, CABG alone may be performed with good overall survival, but with lower event-free survival than those undergoing concomitant mitral valve repair.

BACKGROUND AND AIM OF THE STUDY/OBJECTIVE:Currently, there is no clear consensus on the optimal type of cardiac valve prosthesis that should be placed in women of childbearing age. The risks of reoperative surgery for bioprosthetic valves must be weighed against those of anticoagulation therapy required for mechanical valves. Bioprosthetic valves placed in women of childbearing age are not necessarily superior to mechanical valves in terms of maternal or fetal outcomes. METHODS:A retrospective analysis was performed of early and late outcome in 103 women of childbearing age (mean age 28.3 +/- 5.1 years; range: 18-35 years) who underwent mechanical (n = 63) or biological (n = 40) valve replacement between January 1982 and July 2002. RESULTS:Eleven of the 40 women (28%) with biological valves had 19 pregnancies (13 vaginal births; three caesarean sections). Twelve of the 63 women (19%) with mechanical valves had 37 pregnancies (nine vaginal births, four caesarean sections). All of the women with mechanical valves became pregnant while receiving warfarin, and were subsequently placed on heparin or enoxaparin. No bleeding complications or birth defects were observed in either group. The incidence of miscarriages (32% (12/37) versus 11% (2/19), p = 0.09) and therapeutic abortions (32.4% (12/37) versus 5.3% (1/19), p = 0.06) were greater in the group with mechanical valves than with bioprosthetic valves. Freedom from reoperation at five and 10 years for biological versus mechanical valves was 79% versus 90%, and 38% versus 82%, respectively (p < 0.01), with no reoperative mortality. CONCLUSION/CONCLUSIONS:Biological valves are recommended in women of childbearing age, despite the fact that no birth defects were seen in children born to women with mechanical valves on warfarin, because the teratogenic effects of warfarin may be masked by the high rate of miscarriages and therapeutic abortions in this group.

OBJECTIVE:The aim of this study was to evaluate the feasibility, safety and outcome of skeletonized bilateral internal mammary arteries (BIMA) in patients with unstable angina (UA) undergoing non-elective myocardial revascularization. METHODS:Between January 1997 and December 2003, 758 patients, mean age 62+/-12 years, underwent non-elective coronary artery bypass grafting (CABG) for unstable angina. Two hundred and five (27%) were operated emergently and 503 (73%) urgently. BIMA were employed in 320 (42%) patients (Group B) and isolated left IMA and/or saphenous vein grafts in the remaining 438 (58%) patients (Group M). RESULTS:In-hospital mortality (B = 5.9% and M = 5.3%), and perioperative myocardial infarction (B = 2.2%; M = 1.96%) were similar between the two groups (P = ns). Actuarial survival at 1, 3 and 7 years was 98.7, 97.5 and 96.2% in B and 99, 94.3 and 88.4% in M (P < 0.05 at 7 years follow-up). At 7 years follow-up, the event-free cardiac survival (92 vs. 87%, P = 0.021), angina-free survival (98.6 vs. 94%, P = 0.039), reoperation-free cardiac survival (98 vs. 95%, P = 0.04) and infarct-free cardiac survival (98.7 vs. 96%, P = 0.05) were better in Group B. Multivariate analysis identified age > 65 years (P = 0.02), LVEF < 35% (P = 0.01), > 1 ischemic irreversible area (P = 0.03) as independent predictors for late deaths, while the use of the LIMA (P=0.006) and both mammary arteries (P=0.001) decreased the risk of late deaths. CONCLUSIONS:The use of BIMA in non-elective CABG for UA is safe and effective. Mid-term outcome, however, are superior with improved freedom from cardiac death, from coronary reintervention and from myocardial infarction.

OBJECTIVES/OBJECTIVE:The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. BACKGROUND:With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. METHODS:We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality. RESULTS:There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. CONCLUSIONS:Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

OBJECTIVE:Left ventricular assist device (LVAD) insertion after anterior wall myocardial infarction complicated by cardiogenic shock is an accepted modality of support in select patients. Results of primary revascularization for these patients are poor. We seek to determine the outcomes of patients with myocardial infarction and shock who undergo LVAD insertion alone versus surgical revascularization before LVAD insertion. METHODS:Seventy-four patients at 2 institutions underwent LVAD implantation for myocardial infarction and shock over a 12-year period. Twenty-eight underwent direct LVAD placement, and 46 underwent revascularization through coronary artery bypass grafting before LVAD placement. Variables examined included patient demographics, myocardial infarction-LVAD interval, bridge to transplantation, early mortality (< or = 30 days), survival after LVAD placement, and posttransplantation survivals. RESULTS:There were no differences in demographics between the 2 groups. The group undergoing revascularization before LVAD placement had a lower bridge to transplantation, higher early mortality, and lower overall 6- and 12-month survivals after LVAD placement compared with the group undergoing direct LVAD placement (45.50% vs 70.40%, P = .041; 39.10% vs 14.30%, P = .020; 89.3% and 82.1% vs 54.4% and 52.2%, respectively, P = .006). Posttransplantation survival and LVAD explantation rates were equivalent in both groups. CONCLUSIONS:Coronary artery bypass grafting before LVAD insertion for cardiogenic shock complicating myocardial infarction adversely affects survival. Confirmation of these findings would require conducting a large, multicenter, randomized clinical trial comparing revascularization versus LVAD support as primary therapy in this setting.