Faculty Bibliography

BACKGROUND: We examined whether bilateral internal thoracic artery revascularization (BITA) is safe for reoperative coronary revascularization (reop CABG) or primary CABG at age > or = 80 (CABG > or = 80 yrs) as, these two groups are thought to be at higher risk for death or sternal infection. METHODS: We analyzed 329 such patients between January 1, 1993 and March 31, 2002. These are subgroups of 3200 prospectively New York State risk stratified patients for BITA or SITA (single internal thoracic artery revascularization) of equivalent preoperative risk. In 37/39, BITA > or = 80 since 1996 (1996 > or = 80) the microscope was used and the free right internal thoracic artery was anastomosed to the aorta. Long-term survival was analyzed by Kaplan-Meier curves and in particular among the 36 patients between 1996 and 1997, who were operated five and six years ago (1997 > or = 80). CONCLUSIONS: Mortality and recuperative difference of BITA versus SITA in the reop CABG and CABG > or = 80 years are negligible, as there was no significant difference in hospital mortality, sternal infections, LOS, or Kaplan-Meier survival curves and average long-term survival. However BITA appears to have long-term advantage over SITA in the newer period and beyond 48 months (1996-1997 > or = 80).

Late aneurysm formation is a well-described complication after surgical correction of aortic coarctation. Endovascular repair of such aneurysms avoids the morbidity of conventional reoperative thoracic surgery. We describe a unique case of antegrade endovascular repair of a distal coarctation-associated aneurysm with vascular access acquired through the aortic arch by an upper hemi-sternotomy.

Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-left anterior descending (LAD) territories with minimally invasive direct coronary artery bypass (MIDCAB) using the left internal thoracic artery (LITA) to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to perform full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages associated with the percutaneous treatment of symptomatic coronary stenoses. We investigated whether HR was a valid alternative to conventional coronary artery bypass graft surgery in patients with multivessel coronary artery disease. We also present our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.

Patients with congestive heart failure and altered interventricular conduction enjoy improvements in quality of life and ventricular function after successful resynchronization therapy with biventricular pacing. Technical limitations owing to individual coronary sinus and coronary venous anatomy result in a 10% to 15% failure rate of left ventricular (LV) lead placement through percutaneous approaches. To provide a minimally invasive option for these patients with LV lead failures, we developed a technique of endoscopic, epicardial LV lead implantation with the use of the da Vinci robotic system. The surgical approach targets the posterolateral wall through a novel posterior approach.

Abstract Background: There is a paucity of midterm results comparing the efficacy of minimally invasive direct coronary artery bypass (MIDCAB) and off-pump coronary artery bypass (OPCAB) with standard coronary artery bypass grafting (CABG). In addition, the advent of innovative techniques may have improved midterm results for patients who undergo MIDCAB and OPCAB (MID-OPCAB). The purpose of this study was to evaluate the midterm survival results of higher-risk patient groups who have undergone CABG or MID-OPCAB with or without the use of innovative techniques. Methods: From January 1992 through March 2002, 3670 consecutive patients underwent coronary artery bypass procedures, and their predicted surgical risks were calculated according to the logistic EuroSCORE. The cases of 52 MIDCAB patients and 1796 CABG patients with similar higher-risk EuroSCOREs (11.5 versus 11.4, respectively) who underwent operations from January 1992 to December 1997 were compared (study A). The cases of 89 patients with MID-OPCAB (employing "innovative techniques") and 796 patients with CABG (EuroSCORE, 13.2 versus 13.3, respectively) whose operations took place between 1998 and 2002 were also compared (study B). The National Death Index was used to access mortality data, and Kaplan-Meier curves were constructed for each group of patients. Numbers of arterial grafts, numbers of anastomoses, major complications, in-hospital lengths of stay (LOS), and 30-day mortality rates were noted. Results: In study A, there were no significant differences in the 30-day mortality rates (2.5% versus 3.9%), incidences of major complications (11.5% versus 16.6%), and LOS (13 days versus 11.7 days) for the MID-OPCAB and CABG patients, respectively. CABG patients received more arterial grafts (47.1% versus 28.9%; P =.011), received more distal anastomoses (3.4 versus 2.7; P <.001), and had better survival as estimated by Kaplan-Meier curves (94.5 months versus 82.1 months; P =.023). In study B, there were no differences in 30-day mortality rates (3.1% versus 2.3%) and incidences of major complications (10.1% versus 12.7%) for MID-OPCAB and CABG patients, respectively. CABG patients received more arterial grafts (72% versus 57.3%; P =.004) and more distal anastomoses (3.5 versus 2.8; P <.001). However, LOS was shorter for MID-OPCAB patients (7.2 days versus 9.6 days; P =.019), and there was no difference in survival time as estimated by Kaplan-Meier curves (47 months versus 46.4 months; P =.534). Conclusions: The advent of innovative surgery significantly improved LOS and "equalized" the rate of survival to 5 years in higher-risk MID-OPCAB patients, compared with similar-risk CABG patients.