Arterial Conduits Research Articles

Male-female differences following concomitant coronary artery bypass grafting and aortic valve replacement surgery.

Combined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), and female sex are associated with increased perioperative mortality in clinical risk scores. This study investigated male-female differences in short-term outcome stratified by age groups. All patients undergoing AVR and CABG between January 2001 and June 2021 at our institution were included. 1963 patients were grouped by decades into: 59years and younger (n=127), 60-69 (n=471), 70-79 (n=1070), and 80years and older (n=295). The primary end points of this study were 30 and 180days mortality. Secondary end points were influence of preoperative risk factors and impact of sex on survival and postoperative major adverse events. Female patients showed higher 30 and 180days mortality after combined CABG and AVR surgery (8.3% vs. 4.2%, P<0.01; 15.8% vs. 9.4%, P<0.01). Stratified by age groups, 30 and 180days mortality remained significantly higher in septuagenarians (9.6% vs. 2.5%, P<0.01; 16.3% vs. 7.7%, P<0.01). Females were significantly older, had better preserved left ventricular function, and higher incidence of diabetes mellitus compared with male patients in this subgroup (P<0.01; P=0.01; P<0.01). Additionally, females received significantly less internal mammary artery (IMA) conduits (P<0.01). Female sex (OR: 3.33, 95% CI: [1.76-6.31]; 1.93, [1.22-3.06]), higher age (1.28, [1.13-1.45]; 1.16, [1.06-1.26]), diabetes mellitus (1.93, [1.03-3.60]; 1.70, [1.08-2.67]) and LVEF <30% (3.26, [1.48-7.17]; 2.23, [1.24-4.02]) were correlated with 30 and 180days mortality, respectively. Upon multivariable testing, sex (1.77, [1.21-2.58]) and LVEF <30% (3.71, [2.39-5.76]) remained independent predictors for major adverse postoperative events. Infrequent use of IMA grafts was associated with increased 30 and 180days mortality as well as adverse events (0.47, [0.25-0.87]; 0.46, [0.29-0.72]; 0.61, [0.42-0.88]). Sex disparities in baseline characteristics may delay operative intervention in female patients. The inherent risk profiles might be responsible for outcome differences in septuagenarians.

Clinical and financial outcomes associated with the utilization of right internal mammary artery versus radial artery in multivessel coronary artery bypass grafting

BackgroundMulti-arterial coronary bypass grafting with the left internal mammary artery as a conduit has been shown to offer superior long-term survival compared to single-arterial coronary bypass grafting. Nevertheless, the selection of a secondary conduit between the right internal mammary artery and the radial artery remains controversial. Using a national cohort, we examined the relationships between the right internal mammary artery and the radial artery with acute clinical and financial outcomes. MethodsAdults undergoing on-pump multivessel coronary bypass grafting with left internal mammary artery as the first arterial conduit were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients receiving either the right internal mammary artery or the radial artery, but not both, were included in the analysis. Multivariable regression models were fitted to examine the association between the conduits and in-hospital mortality, as well as additional secondary outcomes. ResultsOf an estimated 49,798 patients undergoing multi-arterial coronary bypass grafting, 29,729 (59.7%) comprised the radial artery cohort. During the study period, the proportion of multi-arterial coronary bypass grafting utilizing the radial artery increased from 51.3% to 65.2% (nptrend <0.001). Following adjustment, the radial artery was associated with reduced odds of in-hospital mortality (adjusted odds ratio 0.44), prolonged mechanical ventilation (adjusted odds ratio 0.78), infectious complications (adjusted odds ratio 0.69), and 30-day nonelective readmission (adjusted odds ratio 0.77, all P < .05). ConclusionDespite no definite endorsement from surgical societies, the radial artery is increasingly utilized as a secondary conduit in multi-arterial coronary bypass grafting. Compared to the right internal mammary artery, the radial artery was associated with lower odds of in-hospital mortality, complications, and reduced healthcare expenditures. These results suggest that whenever feasible, the radial artery should be the favored conduit over the right internal mammary artery. Nevertheless, future studies examining long-term outcomes associated with these vessels remain necessary.

Outcomes of Visceral Arterial Interposition Graft Reconstruction for Locally Advanced Pancreatic Cancer.

The aim of this study is to determine perioperative outcomes and the patency of interposition conduits for visceral arterial reconstruction in this setting. Visceral arterial encasement in locally advanced pancreatic cancer was historically a contraindication for surgery. With modern effective neoadjuvant strategies, our recent experience has made advanced vascular resection and reconstruction feasible in selected patients. A retrospective review was performed of patients undergoing pancreatic tumor resection with en bloc arterial resection and interposition revascularization between 6/2002-10/2022. Endpoints included graft patency, vascular-related complications, reinterventions, morbidity, and mortality. Visceral arterial reconstruction with interposition grafting was performed in 111 patients undergoing en bloc arterial resections for pancreatic cancer. Graft types included autologous arterial conduits (n=66, 58 superficial femoral artery (SFA) and 8 splenic artery), cryopreserved arterial allografts (n=24), autologous saphenous veins (n=12), synthetic conduits (n=8), and composite autologous artery and synthetic (n=1). Perioperative 90-day mortality decreased significantly over time to 5% in the last six years. Vascular complications related to arterial reconstruction occurred in 11% (n=12) and included pseudoaneurysm (n=6), graft thrombus (n=2), stenosis requiring reintervention (n=2), hepatic failure (n=1), and hepatic and intestinal ischemia (n=1). Nine (8%) patients underwent vascular-related reinterventions. After median follow-up of 17-months, primary patency was 81% for the entire cohort and was highest in the SFA group (95%). The donor limb/harvest site complication rate was 8% with 100% primary patency. Visceral arterial resection with interposition reconstruction for locally advanced pancreatic cancer can be performed with acceptable vascular morbidity and durable patency. Autologous SFA was the most suitable conduit for reconstructions in our experience, with highest primary patency.

Nanoparticle aggregation and electro-osmotic propulsion in peristaltic transport of third-grade nanofluids through porous tube

In the modern era, the utilization of electro-kinetic-driven microfluidic pumping procedures spans various biomedical and physiological domains. The present study introduces a mathematical framework for characterizing the hemodynamics of peristaltic blood flow within a porous tube infused with ZrO2 nanoparticles. This model delves into the interactions between buoyancy, electro-osmotic forces, and aggregated nanoparticles to discern their influence on blood flow. We employ a third-grade fluid model to elucidate the rheological behavior of the pseudoplastic fluid which refers to its response to applied shear stress, specifically the relationship between shear rate and viscosity. The collective influence of accommodating heat convection, joule heating and aggregated nanoparticles contributes to the thermal behavior of fluids. The distribution of electric potential within the electric double layer (EDL) is predicted by solving the Poisson–Boltzmann equation. The rescaled equations are simplified using the lubrication and Debye-Hückel models as the underlying frameworks. The novel homotopy perturbation method is employed to obtain solutions for the finalized non-linear partial differential equation. Theoretical assessment of hemodynamic impacts involves plotting graphical configurations for various emerging parameters. As electro-osmotic parameter increase, the bloodstream encounters greater impedance, thereby enhancing the effectiveness of electro-osmotic assistance. Concurrently, elevated convective heat markedly reduces the rate of heat transfer, potentially resulting in a drop in blood temperature. It is important to note that maximum shear stress occurs when the artery is positioned horizontally, underscoring the significant impact of arterial alignment on wall shear stress. Skin friction intensifies with the increasing wall permeability as aggregated nanofluids pass through the arterial conduit. Therefore, aggregation of nanoparticles into the bloodstream yields a broader spectrum of distinctive physiological features. In summary, these findings enable more effective tool and device designs for addressing medication administration challenges and electro-therapies.

Quality improvement initiative to increase radial artery usage as a second arterial conduit in coronary artery bypass grafting.

Use of radial artery as a second arterial graft, compared to a saphenous vein, in coronary artery bypass grafting (CABG) can improve late outcomes. However, the radial artery remains underutilized. We initiated a quality improvement (QI) initiative to increase the usage of radial artery grafts. During our 4-month lead period, we disseminated evidence for radial artery graft usage to surgeons, developed a radial artery decision-making algorithm and adopted endoscopic harvesting. Our QI initiative was conducted over a 6-month period and included a postoperative survey of decision-making for graft selection and obstacles to radial artery usage. Over the 6-month study period, 247 patients received isolated CABG which included 98 (40%) with radial arteries as a second arterial graft and 144 (58%) with greater saphenous veins. Radial artery usage increased with QI initiative implementation by 67% compared to 6 months prior to the study period (60 radial arteries/252 isolated CABG, 24%) (P = 0.006). The survey response rate was 93% (231/247). Barriers to radial artery graft usage were poor quality target vessel or stenosis <80% (24%), patient age >75 years (20%), ejection fraction ≤35% (8%) and renal insufficiency/dialysis (7%). No patients experienced significant complications from radial artery harvest. Our institutional QI initiative was successful in (i) increasing the usage of radial artery as a second arterial graft and (ii) understanding barriers to radial artery graft usage. Implementation of a QI program can improve radial artery usage in CABG with low risk of patient morbidity from radial artery harvest.

Long Term Survival Benefits of Different Conduits Used in Coronary Artery Bypass Graft Surgery- A Single Institutional Practice Over 20 Years.

This study determined hazard factors and long-term survival rate of total arterial coronary artery bypass graft surgery over 20 years in an extensively large, population-based cohort. A total of 2979 patients who underwent isolated CABG from April 1999 to March 2020 were studied in 4 groups- Group-A (bilateral internal mammary artery ± radial artery), Group-B (single internal mammary artery + radial artery ± saphenous vein), Group-C (single internal mammary artery ± saphenous vein; no radial artery), and Group-D (radial artery ± saphenous vein; no internal mammary artery). The study endpoints analysed the correlation between the number and types of grafts with the survival time following isolated CABG surgery. The total arterial revascularization (Group A) group had an admirable mean long-term survival of ~19 years, compared to 18.6 years (Group B), 15.86 years (Group C), and 10.99 years (Group D). A Kaplan-Meier curve demonstrated confidence interval (CI) for study groups- (95% CI 18.33-19.94), (95% CI 18.14-19.06), (95% CI 15.40-16.32), and (95% CI 9.61-12.38) in Group A, B, C, D respectively. In the Holm-Sidak method analysis, significant associations existed between the number of arterial grafts and the long-term outcome. A statistically significant (P≤0.05) long-term survival advantage for arterial grafting was demonstrated, especially total arterial revascularisation over all other combinations except single internal mammary artery + radial artery grafting. In this series, over 20 years, total arterial CABG use has excellent long-term survival, achieving complete myocardial revascularisation. There is no significant difference between the BIMA group and SIMA with radial artery. However, there is a reduced survival with decreased use of arterial conduits.

Aspirin Responsiveness in a Cohort of Pediatric Patients with Right Ventricle to Pulmonary Artery Conduits and Transcatheter Valve Replacement Systems.

The aim of this study was to determine the rate of aspirin responsiveness in a cohort of pediatric patients with in situ xenograft valved right ventricle to pulmonary artery (RV-PA) conduits and/or transcatheter valve replacements (TVR). Aspirin is routinely prescribed to these patients. Optimizing anti-platelet therapy could promote valve longevity and reduce the risk of infective endocarditis in this at-risk group. This was a prospective, observational study. Patients were recruited from both ward and outpatient settings. Patients were eligible if under 18 years and taking aspirin. Non-response to aspirin was defined as >20% platelet aggregation using light transmission platelet aggregometry (LTA) and <50% platelet inhibition by thromboelastography with platelet mapping (TEGPM). Participants were invited to provide a confirmatory sample in cases of aspirin resistance and dose adjustments were made. Thirty patients participated. Median age was 9 years (2 months to 18 years). The majority (93%) had complex right ventricular outflow tract pathology. 13 (43%) had an RV-PA conduit and 24 (80%) had a TVR, with valve situated in conduit in 7 (23%) cases. Rate of aspirin non-response on initial testing was 23% (n=7/30) with median LTA 74.55% (60-76%) and TEG 13.25% (0-44%) in non-responders. Non-responders were more likely to be under 1 year. Two patients required dose increases and one patient non-adherence to dose was identified. Four patients on repeat testing were responsive to aspirin by laboratory tests. The rate of aspirin non-response on laboratory testing in this cohort of patients was 23% and resulted in therapeutic intervention in 10%.

Effect of right internal mammary artery versus radial artery as a second graft vessel in coronary artery bypass grafting on postoperative wound infection in patients: A meta-analysis.

Few studies have shown that radial artery (RA), which is used as a secondary arterial graft, offers superior results compared with right internal thoracic artery (RIMA) in coronary artery bypass grafting (CABG). In a meta-analysis of observational studies starting in 2023, we looked at the effect of re-operation on postoperative infection and haemorrhage in CABG with RA vs. RIMA. The electronic database up to October 2023 was examined in the course of the research. Analysis was carried out on the clinical trials of postoperative wound infections and haemorrhage re-surgery. Among 912 trials associated with CABG, we selected 8 trials to be included in the final data analysis. The main results were secondary wound infection and re-operation after surgery. The odds ratios (OR) and confidence intervals (CIs) were computed on the basis of a randomized or fixed-effect model of wound infection and re-operation. Seven trials showed a significant reduction in the risk of wound infection in RA treated as a secondary artery transplant compared with RIMA (OR, 1.60; 95% CI, 1.03, 2.47 p = 0.04); Four trials showed that RIMA was not significantly different from RA in the rate of re-operation for postoperative bleeding (OR, 1.31; 95% CI, 0.60, 2.88 p = 0.50). In CABG, RA is used as a secondary arterial conduit graft to lower the risk of wound infection in CABG patients.

Feasibility and Intermediate Results of Transcarotid Revascularization with a Prosthetic Conduit

IntroductionTranscarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit. MethodsA single center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy (CEA) based on anatomic features, such as restenosis post-CEA and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance < 5 cm, a CCA diameter < 6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1-29 months. ResultsEight patients underwent ten TCAR procedures via a prosthetic conduit. A total of two procedures (20%) were performed on female patients and eight procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation (SD) 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%. ConclusionsTCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.

Longitudinal analysis of systemic ventricular function and atrioventricular valve function after the Norwood procedure.

To evaluate longitudinal systemic ventricular function and atrioventricular valve regurgitation in patients after the neonatal Norwood procedure. Serial postoperative echocardiographic images before Fontan completion were assessed in neonates who underwent the Norwood procedure between 2001 and 2020. Ventricular function and atrioventricular valve regurgitation were compared between patients with modified Blalock-Taussig shunt and right ventricle to pulmonary artery conduit. A total of 335 patients were identified including 273 hypoplastic left heart syndrome and 62 of its variants. Median age at Norwood was 8 (7-12) days. Modified Blalock-Taussig shunt was performed in 171 patients and the right ventricle to pulmonary artery conduit in 164 patients. Longitudinal ventricular function and atrioventricular valve regurgitation were evaluated using a total of 4352 echocardiograms. After the Norwood procedure, ventricular function was initially worse (1-30 days) but thereafter better (30 days to stage II) in the right ventricle to pulmonary artery conduit group (P < 0.001). After stage II, the ventricular function was inferior in the right ventricle to the pulmonary artery conduit group (P < 0.001). Atrioventricular valve regurgitation between the Norwood procedure and stage II was more frequent in the modified Blalock-Taussig shunt group (P < 0.001). After stage II, there was no significant difference in atrioventricular valve regurgitation between the groups (P = 0.171). The effect of shunt type on haemodynamics after the Norwood procedure seems to vary according to the stage of palliation. After the Norwood, the modified Blalock-Taussig shunt is associated with poorer ventricular function and worse atrioventricular valve regurgitation compared to right ventricle to pulmonary artery conduit. Whereas, after stage II, modified Blalock-Taussig shunt is associated with better ventricular function and comparable atrioventricular valve regurgitation, compared to the right ventricle to pulmonary artery conduit.

Therapeutic strategies based on non-ionizing radiation to prevent venous neointimal hyperplasia: the relevance for stenosed arteriovenous fistula, and the role of vascular compliance.

We have reviewed the development and current status of therapies based on exposure to non-ionizing radiation (with a photon energy less than 10 eV) aimed at suppressing the venous neointimal hyperplasia, and consequentially at avoiding stenosis in arteriovenous grafts. Due to the drawbacks associated with the medical use of ionizing radiation, prominently the radiation-induced cardiovascular disease, the availability of procedures using non-ionizing radiation is becoming a noteworthy objective for the current research. Further, the focus of the review was the use of such procedures for improving the vascular access function and assuring the clinical success of arteriovenous fistulae in hemodialysis patients. Following a brief discussion of the physical principles underlying radiotherapy, the current methods based on non-ionizing radiation, either in use or under development, were described in detail. There are currently five such techniques, including photodynamic therapy (PDT), far-infrared therapy, photochemical tissue passivation (PTP), Alucent vascular scaffolding, and adventitial photocrosslinking. The last three are contingent on the mechanical stiffening achievable by the exogenous photochemical crosslinking of tissular collagen, a process that leads to the decrease of venous compliance. As there are conflicting opinions on the role of compliance mismatch between arterial and venous conduits in a graft, this aspect was also considered in our review.

Right ventricle to pulmonary artery conduit: a comparison of long-term graft-related events between bovine jugular vein conduit, aortic homograft, and porcine-valved conduits.

The optimal conduit for right ventricle to pulmonary artery (RV-PA) reconstruction does not exist. Reinterventions are common due to conduit stenosis and endocarditis. Tailoring conduit choice according to patients' characteristics could improve the outcomes. The study aimed to compare graft-related events (infective endocarditis, transcatheter pulmonary valve replacement (PVR), transcatheter conduit dilatation, surgical conduit replacement, and transcatheter pulmonary branch intervention for RV-PA reconstruction using bovine jugular vein, aortic homograft, and porcine-valved conduits. In a retrospective cohort study, 155 patients with 193 procedures that were done in King Faisal Specialist Hospital and Research Center-Jeddah (KFSHRC JED) for implanting RV-PA conduits from 1999 to 2021 were included. The patients were grouped according to the type of conduit into 3 groups; Group 1 (n=153) received bovine jugular vein (BJVs) grafts, Group 2 (n=29) received aortic homografts, Group 3 (n=11) received porcine-valved conduits. Factors associated with graft-related events were evaluated using stepwise Cox regression analysis. Patients with BJVs were significantly younger than those with porcine-valved conduits 3 (P=0.009). The weight of BJVs patients was significantly lower than homografts (P=0.002) and porcine-valved conduits patients 3 (P<0.001). The conduit size was as expected significantly lower in BJVs patients than patients who received porcine-valved conduits (P<0.001) and patients who received aortic homografts (P<0.001). There was no difference between Group 2 and 3 (P=0.084). Operative mortality occurred in 13 patients: 12 (7.84%) with BJV conduit and 1 (9.09%) with porcine valved conduit (P=0.351). Male gender [odds ratio (OR): 10.04; 95% confidence interval (CI): 1.28-78.86; P=0.028] and smaller conduit size (OR: 0.78; 95% CI: 0.61-0.99; P=0.048) were associated with increased operative mortality. Freedom from graft-related events at 5 and 10 years was 67% and 52% in BJVs patients, 74% and 36% in patients who received aortic homografts, and 53% in patients who received porcine-valved conduits. Factors associated with increased graft-related events were male gender (HR: 1.58; 95% CI: 1.004-2.50, P=0.048) and younger age (HR: 0.995; 95% CI: 0.991-0.999, P=0.041). RV-PA reconstruction was associated with low mortality, unrelated to the conduit type. Reinterventions for graft-related events were common. The durability and graft-related events might be comparable among BJV grafts, aortic homografts, and porcine-valved conduits. Factors associated with increased graft-related events in this study were male gender and younger age.

Outcomes after Biventricular Repair Using a Conduit between the Right Ventricle and Pulmonary Artery in Infancy.

This study investigated the outcomes of biventricular repair using right ventricle to pulmonary artery (RV-PA) conduit placement in patients aged <1 year. Patients aged <1 year who underwent biventricular repair using an RV-PA conduit between 2011 and 2020 were included in this study. The outcomes of interest were death from any cause, conduit reintervention, and conduit dysfunction (peak velocity of ≥3.5 m/sec or moderate or severe regurgitation). In total, 141 patients were enrolled. The median age at initial conduit implantation was 6 months. The median conduit diameter z-score was 1.3. The overall 5-year survival rate was 89.6%. In the multivariable analysis, younger age (p=0.006) and longer cardiopulmonary bypass time (p=0.001) were risk factors for overall mortality. During follow-up, 61 patients required conduit reintervention, and conduit dysfunction occurred in 68 patients. The 5-year freedom from conduit reintervention and dysfunction rates were 52.9% and 45.9%, respectively. In the multivariable analysis, a smaller conduit z-score (p<0.001) was a shared risk factor for both conduit reintervention and dysfunction. Analysis of variance demonstrated a nonlinear relationship between the conduit z-score and conduit reintervention or dysfunction. The hazard ratio was lowest in patients with a conduit z-score of 1.3 for reintervention and a conduit z-score of 1.4 for dysfunction. RV-PA conduit placement can be safely performed in infants. A significant number of patients required conduit reintervention and had conduit dysfunction. A slightly oversized conduit with a z-score of 1.3 may reduce the risk of conduit reintervention or dysfunction.

EDL Induced Electro-magnetized Modified Hybrid Nano-blood Circulation in an Endoscopic Fatty Charged Arterial Indented Tract.

The electrokinetic process for streaming fluids in magnetic environments is emerging due to its immense applications in medical and biochemical industrial domains. In this context, our proposed model seeks to inquire into the hemodynamic characteristics of electro-magnetized blood blended with trihybrid nanoparticles circulation induced by electro-osmotic forces in an endoscopic charged arterial annular indented tract. This steaming model also invokes the consequences of variable Lorentz attractive force, buoyancy force, heat source, viscous and Joule warming, arterial wall properties, and sliding phenomena for featuring more realistic problems in blood flows. Different shapes of suspended trihybrid nanoparticles, such as spheres, bricks, cylinders, and platelets, are included in the model formation. Electro-magnetized modified hybrid nano-blood is an electro-conductive solution comprising blood as base fluid and magnetized trihybrid nanoparticles (copper, gold, and alumina). Closed-form solution in terms of Bessel's functions is gotten for electro-osmotic potential due to the electric double layer (EDL). The homotopy perturbation methodology is implemented in order to track down the convergent series solutions of non-linear coupled flow equations being elicited. The physical attributes of distinct evolving parameters on the different dimensionless hemodynamic profiles and quantities of interest are elucidated evocatively via a sort of graphs and charts. The ancillary outcomes proved that the Debye-Hückel parameter and Helmholtz-Smoluchowski velocity have a dual impact on the ionized bloodstream. The bloodstream rapidity is alleviated/boosted for the assisting/opposing electroosmosis process. Cooling of ionized blood in the endoscopic arterial conduit is achieved with lower Hartmann numbers. Copper-gold-alumina/blood exhibits a superior heat transmission rate across the arterial wall than copper-gold-blood, copper-blood, and pure blood. Additionally, the contour topology for the bloodstream in the flow domain is briefly elaborated. The contour distribution is significantly amended due to the variant of the Debye-Hückel parameter. The model's new findings may be invaluable in electro-magneto-endoscopic operation, electro-magneto-treatment for cancer, surgical process, etc.

Pitfalls of Robicsek 's Procedure: Safest Avant -Garde Alternatives to Reduce Sternum Surgical Complications

Robicsek's technique is a surgical methodology mainly used for sternal dehiscence, stabilization of the chest wall, and maintaining respiratory dynamics. Returning to an infected and anatomically altered scenario after cardiac surgery fosters a high risk of rupture, tears of previous repairs, and vascular bypasses. Classically, the dense adhesion of the left internal mammary artery to the posterior plate of the sternum makes the dissection of half of the fractured and dehisced sternum a prone situation for transection avulsion of the artery conduit, requiring ligating the most critical bypass to the heart. Our proposal brings a solid and safe surgical alternative to avoid dealing with the dangerous situation of dissecting the posterior sternum to perform Robicsek's procedure.

Coronary Artery Bypass Surgery: Evidence-Based Practice.

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.

Post-right ventricle to pulmonary artery conduit: short- and intermediate-term outcomes: a single-center study

BackgroundSurgery for congenital heart disease has progressed by leaps and bounds in the last few decades, but the right ventricular outflow tract continues to pose a challenge to the congenital heart surgeon.ObjectivesWe aim to describe the outcomes of patients with CHD who had surgical placement of right ventricle to pulmonary artery conduits with a focus on the risk factors for redo-surgery.MethodsWe performed a retrospective single-center clinical data review of patients who had RVOT surgery using RV-to-PA conduitsResultsThirty-three patients (54.5% males) were included. The mean age at first conduit placement was 3.57 ± 3.18 years, mean conduit size conduit was 14.45 ± 3.85 mm. 51.5% of patients received Contegra tubes. On a mean follow-up of 2.07 ± 2.36 years, 45.5% of patients underwent RV-to-PA conduits redo replacement after 5.67 ± 3.25 years from the first surgery, 2 patients underwent re-intervention for the second time, 7 patients had transcatheter interventions on RVOT or branch PAs. The main mode of conduit failure was stenosis. The median survival without the need for surgical reintervention was 2.5 years for the non-contegra subgroup versus 3 years for the contegra subgroup (P = 0.59). we predicted that 100% of the study group would require redo surgery for conduit replacement within the first 11 years post-initial surgery. For every year of age increase at follow-up, the hazard ratio for redo surgery increases by a factor of 1.47. For every year of age increase at the time of first operation, the hazard ratio for redo surgery decreases by a factor of 0.7.ConclusionsThe use of conduits to treat the RV to PA discontinuity is a cornerstone in treating congenital heart diseases. Nevertheless, conduit failure and replacement are inevitable. In our experience the higher the age at the first conduit, the longer the re-intervention-free survival period.

A Valved Expanded Polytetrafluoroethylene Conduit can Acquire Endothelium After Implantation.

We demonstrate histopathology, neointimal proliferation, and neo-endothelialization in an explanted valved expanded polytetrafluoroethylene (ePTFE) conduit 40 months postimplantation that was void of calcification and inflammation, confirmed by CD-31 positivity on immunohistochemistry. Grossly, there was no distortion with preserved leaflets and lack of calcification. Good biocompatibility, nonreactivity, and low antigenicity, combined with neointimal and endothelial layer generation within the conduit might explain the low infection rates and minimal thrombogenicity. These findings support the use of handmade, valved ePTFE conduits as an economically viable option as a right ventricle to pulmonary artery conduit.

The VEST External Support for Saphenous Vein Grafts in Coronary Surgery: A Review of Randomized Clinical Trials.

Saphenous vein grafts (SVGs) are the most frequently used conduits in coronary artery bypass grafting (CABG), but their higher rate of occlusion compared to arterial conduits remains a concern. Previous studies have shown that SVG failure is mainly driven by intimal hyperplasia, an adaptative response to higher pressures of the arterial circulation. The VESTTM device (Vascular Graft Solutions, Tel Aviv, Israel), an external support designed to mitigate intimal hyperplasia in SVGs, has been tested in few clinical trials (RCTs). Herein, we descriptively evaluated the randomized evidence on the VEST device.

Impact of calorie intake and weight gain after Norwood procedure on the outcome of stage II palliation.

This study aimed to assess the impact of caloric intake and weight-for-age-Z-score after the Norwood procedure on the outcome of bidirectional cavopulmonary shunt. A total of 153 neonates who underwent the Norwood procedure between 2012 and 2020 were surveyed. Postoperative daily caloric intake and weight-for-age-Z-score up to five months were calculated, and their impact on outcome after bidirectional cavopulmonary shunt was analysed. Median age and weight at the Norwood procedure were 9 days and 3.2 kg, respectively. Modified Blalock-Taussig shunt was used in 95 patients and right ventricle to pulmonary artery conduit in 58. Postoperatively, total caloric intake gradually increased, whereas weight-for-age-Z-score constantly decreased. Early and inter-stage mortality before stage II correlated with low caloric intake. Older age (p = 0.023) at Norwood, lower weight (p < 0.001) at Norwood, and longer intubation (p = 0.004) were correlated with low weight-for-age-Z-score (< -3.0) at 2 months of age. Patients with weight-for-age-Z-score < -3.0 at 2 months of age had lower survival after stage II compared to those with weight-for-age-Z-score of -3.0 or more (85.3 versus 92.9% at 3 years after stage II, p = 0.017). There was no difference between inter-stage weight gain and survival after bidirectional cavopulmonary shunt between the shunt types. Weight-for-age-Z-score decreased continuously throughout the first 5 months after the Norwood procedure. Age and weight at Norwood and intubation time were associated with weight gain. Inter-stage low weight gain (Z-score < -3) was a risk for survival after stage II.