Faculty Bibliography

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.

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.

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.

OBJECTIVE: To evaluate the accuracy of predicting long-term mortality in patients with coronary artery bypass grafting (CABG) by using the European system for cardiac operative risk evaluation (EuroSCORE). METHODS: Medical records of patients with CABG (n=3760) between January 1992 and March 2002 were retrospectively reviewed and their predicted surgical risk was calculated according to the standard (study A) and logistic (study B) EuroSCORE. In study A the patients were divided into six groups: 0-2 (n=610), 3-5 (n=1479), 6-8 (n=1099), 9-11 (n=452), 12-14 (n=103) and >14 (n=17). In study B the patients were divided into seven groups: 0.00-2.00 (n=447), 2.01-5.00 (n=1190), 5.01-10.00 (n=890), 10.01-20.00 (n=686), 20.01-30.00 (n=234), 30.01-60.00 (n=254) and >60.00 (n=59). Long-term survival was obtained by the National Death Index and Kaplan-Meier curves were constructed and compared employing the log-rank test. Multivariate Cox regression analysis was performed in order to control for pre, intra and postoperative factors and adjusted hazard ratios were calculated for standard and logistic EuroSCORE groups. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination ability of the EuroSCORE. RESULTS: In study A there were differences among the six groups in 30-day mortality (0.7%, 1.0%, 3.1%, 4.6%, 13.6% and 23.5%; P<0.001), in major complications (8.5%, 10.4%, 16.2%, 20.4%, 31.1% and 35.3%; P<0.001) as well as in actuarial long-term survival (86.2%, 79.6%, 53.6%, 37.9%, 24.9% and 0% from EuroSCORE 0-2 to >14; P<0.001). In study B there were differences among the seven groups in 30-day mortality (0.9%, 1.1%, 1.2%, 3.6%, 3.4%, 8.7% and 15.3%; P<0.001), major complications (8.5%, 10.1%, 12.1%, 18.4%, 16.2%, 26.0% and 30.5%; P<0.001) as well as in actuarial long-term survival (89.5%, 79.9%, 66.9%, 51.0%, 40.3%, 38.4% and 13.7% from EuroSCORE 0.00-2.00 to >60.00; P<0.001). Multivariate Cox regression analysis confirmed that EuroSCORE (standard or logistic) was a statistically significant predictor for long-term mortality, while the area under the ROC curve was 0.72 for either standard or logistic EuroSCORE. CONCLUSION: The predicted surgical risk in CABG patients as calculated by standard or logistic EuroSCORE is a strong predictor for long-term survival in addition to predicting operative survival for which it was originally designed.

BACKGROUND: The purpose of this study was to define the early outcome and the potential for midterm survival in patients with left ventricular dysfunction (LVD) who undergo off-pump coronary artery bypass (OPCAB) and to compare these results with those of conventional coronary artery bypass grafting (CABG). METHODS: Medical records of patients with LVD (n = 732) between January 1998 and March 2002 were retrospectively reviewed. There were 523 patients with moderate LVD (ejection fraction, 30%-50%; 463 CABG versus 60 OPCAB) and 209 patients with severe LVD (ejection fraction, < 30%; 136 CABG versus 73 OPCAB). Midterm survival data (mean follow-up, 2.3 years) were obtained from the National Death Index. Groups were compared by multivariate Cox proportional hazard models, and Kaplan-Meier curves were plotted. RESULTS: CABG patients had lower European System for Cardiac Operative Risk Evaluation values (5.3 versus 7.2 and 8.0 versus 9.6 in moderate and severe LVD subgroups, respectively; P < .001). There were no differences (OPCAB versus CABG) in 30-day mortality (3.3% versus 1.9%, moderate LVD group, P = .366; 6.8% versus 4.4%, severe LVD group, P = .521), length of stay (9.3 versus 8.6 days, moderate LVD group, P = .683; 11.9 versus 11.8 days, severe LVD group, P = .423), and postoperative complications (13.3% versus 11.0%, moderate LVD group, P = 0.663; 16.4% versus 20.6%, severe LVD group, P = .581). Successful coronary bypass in patients with severe LVD was associated with 68.2% and 66.2% actuarial 48-month survival rates for the CABG and OPCAB patients, respectively (P = .336), and these rates rose to 86.0% and 82.9% in patients with moderate LVD (P = .121). When CABG patients with moderate LVD were considered the reference group, the adjusted hazard ratio of OPCAB patients with moderate LVD for midterm mortality was 1.32 (95% confidence interval, 0.61-2.87; P = .481). CABG and OPCAB patients with severe LVD had the same adjusted hazard ratio of 1.86, and this figure was statistically significant compared with the value for the reference group (P = .011 and P = .039, respectively). CONCLUSIONS: Patients with LVD can derive midterm benefit from coronary bypass. OPCAB in higher-risk patients had early and midterm outcomes similar to those of CABG.

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.

Hypereosinophilia can cause severe endomyocardial fibrosis with subsequent restrictive cardiac disease and endocardial lesions. We present a case of a 37-year-old man with known hypereosinophilia, followed with yearly echocardiograms, who presented acutely with myocardial infarction and aortic outflow tract obstruction. At surgery, a broad based eosinophilic thrombus was found that had obstructed the aortic outflow tract. The possibility of the rapid emergence of such obstructive thrombotic lesions in hypereosinophilic syndromes warrants very close echocardiographic surveillance.