Average Number Of Grafts Research Articles

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review.

We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD). A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date. A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days). MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Analysis of the Perioperative Course of Cardiac Surgery Patients with Coronary Artery Disease and Heart Valve Dysfunction

The aim. To analyze the perioperative course of cardiac surgery patients with coronary artery disease (CAD) and heart valve dysfunction. Materials and methods. Retrospective analysis of 41 consecutive cardiac surgery patients (mean age 61.6 ± 7.8 years) with CAD and heart valve dysfunction who were operated on and discharged from the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. All the patients underwent standard clinical and laboratory examinations, coronary angiography, on-pump cardiosurgical intervention. Results. The patients were divided into three subgroups: patients with post-infarction left ventricular aneurysm (LVA) combined with insufficiency of atrioventricular valves, n = 15 (36.6%); those with ischemic mitral insufficiency (MI), n = 11 (26.8%); and patients with CAD combined with aortic valve disease, n = 15 (36.6%). During echocardiographic study, decreased left ventricular ejection fraction was found in patients with LVA and with ischemic MI: 33 ± 6.4% and 39.4 ± 7.8%, respectively, and in patients with aortic valve disease, left ventricular ejection fraction averaged 48.2 ± 9.9% (p < 0.0001). According to the EuroSCORE II scale, the average risk was 11.8 ± 7.3%. All the patients were discussed by the heart team to choose the optimal method of cardiosurgical correction. In order to reduce the ischemic time, off-pump coronary bypass surgery was performed at the first stage, and the second stage was on-pump correction of valvular dysfunction. The average number of grafts was 2.8 ± 1.4, but the largest number of grafts was in the subgroup of ischemic MI: 4 ± 0.9 (p < 0.005). Mitral valve replacement in patients with LVA was performed through LVA in 12 patients. Acute heart failure, acute renal failure often developed in patients after correction of ischemic MI (p < 0.005). On the 1st day after the operation, there was an increase in average glucose values from 6.6 ± 2.8 to 10.3 ± 2.9 mmol/L (p < 0.0001), a decrease in glomerular filtration rate from 72.1 ± 15.3 to 57 ± 18.8 mL/min/1.73 m2 (p = 0.0001), the above indicators returned to the initial level at discharge (p < 0.0001). Conclusions. Off-pump myocardial revascularization in patients with CAD and dysfunction of the heart valves can significantly reduce the ischemic time. The method of mitral valve replacement through LVA developed in the department allowed to reduce the perfusion time (p = 0.0023) and the duration of the operation (p < 0.005). Preoperative discussion of examination data of patients by the heart team, thorough preparation for cardiac surgery, timely response to changes in laboratory parameters with correction of drug treatment avoid complications.

Success Rate of Coronary Artery Bypass Grafting on Elderly Patients in Dr. Soetomo General Academic Hospital, Surabaya

Highlights: CABG is the most performed cardiac surgery in Indonesia, and most patients undergoing this surgery are above 60 years old. CABG success rate is not significantly influenced solely by the patient’s age but also by several perioperative characteristics such as gender, comorbidities, and other variables included in the calculation of EuroSCORE II. Abstract Introduction: Coronary artery disease (CAD) causes more than a quarter of deaths in Indonesia and is found to be more prevalent in the elderly (≥60 years old). Treatment includes coronary artery bypass grafting (CABG), the most-performed cardiac surgery in Indonesia. This study aimed to determine the short-term and one-year postoperative success, morbidity, and mortality rates with their causes in Dr. Soetomo General Academic Hospital, Surabaya. Methods: This was a cross-sectional retrospective study using secondary data obtained from 85 medical records of CABG patients aged ≥60 years old in the Department of Thoracic, Cardiac, and Vascular Surgery, Dr. Soetomo General Academic Hospital, Surabaya, from January 2018 to December 2020. Aside from descriptive statistics, logistic regression was conducted to assess the relationship between EuroSCORE II and the success of CABG in elderly patients. Results: Patients were mostly male in their sixties with a mean of 65.5 ± 4.9 years old, had three-vessel disease, and had a predicted mortality rate of 1.6%. The average number of grafts used was 3.3 ± 0.7, and the average length of hospital stay was 7.4 ± 2.4 days. The morbidity rate was 71.8%, with bleeding as the most common complication, a 17.6% mortality rate with septic shock as the most frequent cause, and a success rate of 82.4% (short-term) and 80% (one-year postoperative). Higher EuroSCORE II was found to significantly decrease the probability of both short-term and one-year postoperative success. Conclusion: The success rates of CABG in Dr. Soetomo General Academic Hospital, Surabaya, were 82.4% (short-term) and 80% (one-year postoperative), negatively correlated with EuroSCORE II.

Influence of Body Mass Index and Glucose Metabolism on Results of Cabg for High Risk Patients

Aimto study influence of BMI and glucose metabolism on results of CABG for high-risk patients. Materialretrospective analysis of 194 high-risk patients who were discharged after CABG. Resultsanalysis of the BMI shown that 35 (18.04%) patients had normal weight, 86 (44.3%) - were overweight, I stage obesity had 58 (29.8%), II stage – 13 (6.7%), III st. obesity diagnosed in 2 (1.03%) cases. Impaired glucose metabolism was found in 132 (68.04%) patients. Type 2 DM had 50 (25.7%) patients, between which only 4 (8%) had BMI < 25 kg/m2, 46 (92%) – BMI > 25 kg/m2. IGT had 82 (42.2%) patients among which 15 (18.2%) had normal weight, 67 (81.7%) – BMI > 25 kg/m2. For all patients we performed CABG, in 187 (96.3%) cases off-pump. Average number of grafts was 3.37±0.96. Compering postoperative period of patients with BMI < 25 kg/m2 & normal glucose metabolism (n=16) against patients with BMI > 25 kg/m2 & impaired glucose metabolism (n=113) we found atrial fibrillation in 1 (6.25%) against 30 (26.5%) cases (p=0.0753); neurological dysfunctions 0 (0%) against 6 (5.3%), p=0.3452; wound infections 0 (0%) against 4 (3.5%), p=0.4446; pneumonia 0 (0%) against 4 (3.5%), p=0.4446 and acute kidney injury 0 (0%) against 2 (1.7%), p=0.5917. Conclusionsin high-risk patients with CAD before CABG impaired glucose metabolism diagnosed in 132 (68.04%) cases and BMI > 25 kg/m2 – in 159 (81.9%). Metabolic disorders influenced on appearance of infection, neurological and arrhythmic complications in early postoperative period. Off-pump CABG minimizes postoperative complications for high-risk patients.

Ninety-seven cases of experiences with the left thoracotomy approach for off-pump conventional revascularization: a retrospective cohort study.

Minimally invasive coronary surgery-coronary artery bypass grafting (MICS CABG) is well adopted in clinical practice. However, this procedure did not really achieve conventional complete revascularization. The present study aimed to explore the feasibility and safety of conventional revascularization via the left thoracotomy (8-10 cm) approach. From January 2020 to March 2022, a total of 97 consecutive patients who needed coronary artery revascularization were operated on using this technique. The patients' preoperative, intraoperative, postoperative, and follow-up data were collected. Perioperative variables were compared between the single graft and non-single graft groups. All patients received dual-source computerized tomographic angiography at 1-week postoperatively to evaluate the graft patency and detect pulmonary embolism and aortic dissection. The patients were followed up for 3-27 months. The mean age of the entire cohort was 61.5±8.8 years, there were 16 (16.5%) female patients, and 1-4 grafts were performed per patient. There were no conversions to median sternotomy or on-pump CABG. The average number of grafts was 1.9±0.9, and that of the non-single graft group was 2.5±0.6. Among the 97 included patients, one patient in the single graft group suffered from aspiration pneumonia after a stroke and died. The 30-day mortality was 1.0% (one patient), one patient required re-exploration for bleeding (1.1%), and a total of 191 grafts were performed. All grafts were unobstructed except for one graft to the obtuse marginal branch (OM) (0.5%). Follow-up was performed by phone or via outpatient visits and was available for 92 patients (95%). During the follow-up period, 1 (1.1%) patient suffered an acute myocardial infarction and received percutaneous coronary intervention with no redo-surgery. All patients are alive and angina-free. Left thoracotomy for conventional revascularization is a safe procedure for appropriately selected patients, with few early complications and good early and mid-term results. More cases are ongoing and long-term results are in observation.

The Influence of Obesity on Perioperative Course in High-Risk Patients with Coronary Artery Disease in Cardiac Surgery

The aim. To analyze the influence of obesity on the perioperative course in high-risk patients with coronary artery disease (CAD) in cardiac surgery.&#x0D; Material and methods. Retrospective analysis of 354 randomly selected high-risk patients with CAD (ES II &gt; 5%) who underwent surgical intervention and were discharged from the Institute in the period from 2009 to 2019. All the patients underwent routine clinical tests, ECG, echocardiography, coronary angiography and surgical revascularization of the myocardium with correction of concomitant cardiac pathology. Among the patients of the experimental group, 194 (54.8%) had CAD, 132 (37.2%) had postinfarction left ventricular aneurysm, 12 (3.3%) suffered from ischemic mitral regurgitation, 16 (4.5%) patients had CAD and aortic valve disease.&#x0D; Results. Among high-risk patients with CAD, 287 (81.07%) had BMI &gt; 25 kg/m2. Carbohydrate metabolism disorders were found in 208 (72.4%) overweight patients. Type 2 diabetes mellitus (DM) was diagnosed in 78 (27.1%) patients, glucose intolerance was found in 130 (45.2%) cases. Risk stratification according to the ES II scale showed maximum risk (9.8%) in patients with normal body weight and the lowest risk (5.23%) in those with grade III obesity: however, the scale does not take into account anthropometric data. With the increase in body weight, the average number of grafts decreased (3.1 at a BMI of 25-35 kg/m2, 2.6 at a BMI &gt; 40 kg/m2) and the use of internal thoracic arteries increased: 53.7% in patients with normal weight, 66.6% in those with grade III obesity. The level of blood transfusions was the highest (55.2%) in patients with normal weight, and in those with grade III obesity no blood transfusions were performed. Postoperative atrial fibrillation occurred in 14 (20.8%) patients with BMI up to 25 kg/m2, in 30 (28.03%) with BMI 30-29.9 kg/m2 and in 8 (34.7%) patients with grade II obesity. Regardless of body weight, there was a trend towards increase in glucose levels on the first postoperative day with subnormalization until discharge. Acute kidney injury was detected in 3 (4.4%) patients with normal weight, 3 (1.94%) overweight patients, 3 (2.8%) patients with grade I obesity and 1 (33.3%) patient with morbid obesity.&#x0D; Conclusions. Timely preventive measures can help to avoid serious complications even in high-risk patients with obesity. Despite the fact that overweight patients have more severe perioperative period, experience of our Institute allows to operate and treat high-risk patients successfully regardless of their body weight.

Midterm outcome of off-pumpCABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce. A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed. The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR,88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868)and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676). OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes,albeitwith high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.

Comparison of On-Pump and Off-Pump Coronary Artery Bypass Grafting. Our experience of participation in the international study

&#x0D; Aim. To present our experience in the international, multicenter, randomized clinical trial CORONARY (CABG Off or On Pump Revascularization Study) in which on-pump and off-pump CABG was compared.&#x0D; Materials and methods. Eleven patients who signed informed consent and matched at least 1 inclusion criterion according to the CORONARY study protocol were randomized in Institute site. All the patients completed the EuroQol-5D questionnaire and underwent neurocognitive tests (MOCA, DSS, Trial Making test).&#x0D; Results. The mean age of the enrolled patients was 62.9 ± 6.2 years. All the patients (100%) had myocardial infarction (MI) in anamnesis, 4 (36.35%) patients had cerebrovascular disease (CVD), 5 (45.4%) patients had chronic kidney disease (CKD), and 4 (36.35%) had diabetes mellitus (DM). The average number of hemodynamically marked coronary artery stenoses was 2.45 ± 0.78, the left main lesion was diagnosed in 2 (18.18%) cases. The severity of the patients’ condition according to the ES II scale averaged 4.9 ± 1.23%. Five (45.5%) patients underwent on-pump CABG, and offpump CABG was performed in 6 (54.5%) cases. The average on-pump time was 122.8 ± 23.5 minutes; the aortic clamp time was 68.4 ± 9.6 minutes. The average number of grafts was 3.5 ± 0.78. In the postoperative period, paroxysm of atrial fibrillation occurred in 4 (36.35%) patients. One (9.09%) patient had fatal ischemic stroke on day 5 after CABG. The patients were discharged on average within 8.5 ± 2.7 days. According to the study protocol, the condition of patients was monitored annually by telephone; 8 (72.7%) patients completed all visits. In 1 (9.09%) patient with recurrence of angina pectoris in 4 years after CABG we performed repeat CABG.&#x0D; Conclusions. According to the Institute experience of participation in the CORONARY study, there was 1 (9.09%) death due fatal ischemic stroke in the on-pump CABG group. One (9.09%) patient from the off-pump CABG group had repeated CABG. These results of small studies are generating debates in terms of the effectiveness of CABG technique. In multicenter CORONARY trial the rate of mortality, stroke, myocardial infarction, kidney failure, repeated revascularization of myocardium during 5 years of follow-up was similar in on-pump and off-pump CABG patients groups.

MICS CABG: a single-center experience of the first 100 cases.

To study the learning curve and outcomes of the first 100 cases of minimally invasive cardiac surgery (MICS) coronary artery bypass grafting (CABG) performed at our center. From January 2017 to November 2019, a total of 100 patients underwent CABG via left anterior thoracotomy approach. We have studied the operative times within the MICS CABG patients to analyze our learning curve. We also studied the postoperative outcomes and compared these with those of patients who underwent sternotomy during the same period. The mean age was 59.33 ± 9.95 (range 37-82) years. The numbers of males and females were 72 and 28 respectively. The preoperative average ejection fraction (EF) was 51.08 ± 9.75%. All these patients underwent CABG via left thoracotomy approach, after satisfying the exclusion criteria. All patients received left internal mammary artery (LIMA) to left anterior descending (LAD) as a standard graft, with the radial artery and saphenous vein being the next alternative conduits. The average length of the incision was 6.06 ± 0.45cm. Only 2 cases were done on pump. The average number of grafts per patient was 2.33 ± 0.92. The mean operative time was 132.40 ± 11.56min. The mean duration of ventilation was 4.79 ± 1.90h and average intensive care unit (ICU) stay was 2.62 ± 0.84days. There was one conversion and no mortalities in our study. We had analyzed our operative times and noticed a significant reduction after the first 20 cases, which was our learning curve. MICS CABG can be performed for multivessel disease with the same comfort as for a single or a double vessel disease, once the learning curve has been achieved. Only significant difference from the sternotomy approach was noted in the longer operative times for MICS CABG during the learning curve, and not thereafter. Significant benefits of MICS over sternotomy were noticed in the immediate postoperative parameters like duration of ventilation, mean drainage, postoperative pain, ICU stay, and hospital stay, with no difference in postoperative adverse events.

Long-term survival following on-pump and off-pump coronary artery bypass graft surgery: a propensity score-matched analysis

Recent studies have once again brought into focus the long-term survival following off-pump coronary artery bypass grafting (OPCAB) compared with conventional on-pump coronary artery bypass grafting surgery (ONCAB). The aim of this study was to compare the long-term risk-adjusted survival rates in patients undergoing coronary artery bypass grafting (CABG) using these 2 techniques. We undertook a propensity score-matched analysis of 10293 patients who underwent CABG at our single institution between 2000 and 2016. A logistic regression model was fitted using 14 covariates and their 2-way interactions to calculate an estimated propensity score [area under curve (AUC) 0.69], from which 1:1 nearest neighbour matching was performed. Patient survival was assessed using the Kaplan-Meier method and log-rank test. Of the total cohort, 8319 patients had ONCAB and 1974 had OPCAB. Prior to matching, the OPCAB group had marginally higher EuroSCORE [3.7 ± 2.7 vs 3.5 ± 3, median (interquartile range) 3 (2-5) vs 3 (2-5), P = 0.016] and significantly lower average number of grafts per patient (2.39 ± 0.72 vs 2.75 ± 0.48, P < 0.001). Post-matching distributions between OPCAB and ONCAB showed a substantial improvement in balance in preoperative patient characteristics. The 2 surgery groups differed significantly in survival (P < 0.001). OPCAB demonstrated improved long-term survival at 10 years [84.8%, 95% confidence interval (CI) (82.7-86.9%) vs 75.8%, 95% CI (73.4-78.2%)] and 15 years [65.4%, 95% CI (61.4-69.6%) vs 58.5%, 95% CI (54.9-62.3%)]. Results of sensitivity analysis for 1:2 and 1:3 matched data were in concordance with these findings of survival. At our institution, selected patients who underwent OPCAB had lower in-hospital morbidity and improved long-term survival when compared with a matched population of ONCAB patients.

Effect of Off-pump Coronary Artery Bypass Graft Surgery in Patients with Diabetes Mellitus

Background &amp; objective : Myocardial revascularization in diabetic patients is challenging. Off pump coronary artery bypass (OPCAB) surgery has been widely used for the treatment of coronary artery disease. The goal of this study was to compare outcomes of OPCAB in diabetic patients relative to non diabetic patients.&#x0D; Methods:The present prospective study was conducted between January 2014 to June 2017. During the period a total of 193 patients (of whom 70 had diabetes and 123 patients were non-diabetics) were included in the study. All of them underwent coronary artery bypass grafting (CABG) without cardiopulmonary bypass surgery. The early clinical outcomes of OPCAB were evaluated during the postoperative hospital stay.&#x0D; Result: Over three-quarters of the patients in both diabetic and non-diabetic groups were ≥ 50 years old with no significant intergroup difference (p = 0.825). Majority(90%) of the patients in either group was male (p = 0.786). Nearly half (48.5%) of the patients in diabetic and 45% in non-diabetic group were overweight or obese (p = 0.557). The smokers weremuch higher in non-diabetic group than that in the diabetics (p = 0.009). The average number of grafts needed was considerably higher in the diabetic group (p = 0.079). All the postoperative outcome variables like pneumonia, stroke, arrhythmia, renal failure requiring dialysis and postoperative mortality in both the groups were almost identical (p &gt; 0.05).&#x0D; Conclusion: Off-pump coronary artery bypassis the preferred choice of revascularization for multi-vessel coronary artery disease in diabetic patients. However, continuous, strict glycemic control is essential to have a good postoperative outcome.&#x0D; Ibrahim Card Med J 2018; 8 (1&amp;2): 10-16

OC26 EXTERNAL STENTING OF VEIN GRAFTS IN OFF PUMP CORONARY BYPASS SURGERY AND SEQUENTIAL GRAFTING: INTERMEDIATE RESULTS FROM A SINGLE CENTER PROSPECTIVE STUDY

Abstract Background: External stenting of vein grafts has been shown to reduce graft disease by mitigating intimal hyperplasia and improving flow pattern in on-pump single vein graft context. Aim of study is to evaluate usability and clinical outcome of external stenting also in patients undergoing beating-heart sequential grafting receiving multiple external stents per patient. Methods: Thirty patients undergoing CABG had the venous grafts supported with VEST (VascularGraftSolutions, Israel) and were prospectively followed-up via phone call and/or visit every 6 months. Major Adverse Cardiac and Cerebrovascular Events (MACCE) were recorded. Planned follow-up is 5 years. Results: Mean age was 69.0, 86.7% were males, mean Euroscore and ejection fraction were 5.40% ± 4.92% and 56.8% ± 7.4. Veins were harvested in an open manner. Average number of grafts per patient was 3.2. Each patient had either single vein graft (n = 20), or sequential vein grafts (n = 10) supported with VEST. All patients were discharged alive from the hospital after surgery. One patient experienced transient ischemic attack during in-hospital stay and fully recovered before discharge. Follow up was complete for all patients, mean follow time of 16 months (range 1–31 months). During the follow up period, MACCE rate were 0% and no additional adverse events were reported. CT angiography performed to patients arriving at 1 year follow-up confirmed all grafts were patent. Conclusions: External stenting of saphenous vein grafts is technically feasible in off pump CABG procedures and sequential grafting. Intermediate follow up of up to 30 months suggest that it's safe and not associated with major clinical events.

Outcome of Coronary Artery Bypass Graft with On-pump Beating-heart Technique

Background: This paper intends to evaluate the effects of on-pump beating-heart coronary artery bypass graft (CABG) in patients with coronary artery disease. Studies have shown that this surgical procedure can have acceptable results. Objectives: This study intends to share experiences and results of on-pump beating-heart CABG. Methods: We reported preliminary results related to mortality and morbidity in patients who underwent CABG in the period from 2015 to 2017 in Ghaem hospital, Mashhad, Iran. Results: 80 patients, in the period from 2015to 2017, underwent general anesthesia and on-pump beating-heart CABG surgery was done for them. The average number of grafts was 3.18± 0.474 and two patients died, unfortunately: one during surgery and one in ICU. There were no postoperative myocardial infarctions during the study. None of the patients reported kidney dysfunction. The average length of hospitalization was 4±1.11 days and the mean follow-up of the patients was 6 months. The average ejection fraction (EF) of patients was 43. 28± 9.58. Conclusion: In the last decade there has been a big challenge between using off-pump CABG and on-pump CABG, on-pump beating method could present acceptable and effective results.

Minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries: Will this be the future?

ObjectiveThe aim was to show that total arterial revascularization via a left minithoracotomy using bilateral internal thoracic arteries was not only feasible but also a safe and reproducible procedure with excellent midterm outcomes. MethodsFrom August 2011 to August 2016, 819 patients underwent off-pump minimally invasive multivessel coronary artery bypass grafting using bilateral internal thoracic arteries harvested through a 2-inch left minithoracotomy incision, and complete revascularization of the myocardium was performed using the left internal thoracic artery-right internal thoracic artery Y composite conduit. ResultsA total of 819 patients underwent minimally invasive total arterial myocardial revascularization using bilateral internal thoracic arteries (left internal thoracic artery-right internal thoracic artery Y composite conduit) via a left minithoracotomy. The average number of grafts was 3.1. A total of 171 patients (21%) had 4 grafts, and 557 patients (68%) had 3 grafts. There were 6 mortalities (0.7%), and 4 patients (0.4%) had an elective conversion to sternotomy because of hemodynamic instability. The average hospital stay was 3.1 days. Coronary angiograms were performed in 195 patients (23%), and computed tomography angiograms were performed in 172 patients (21%) at 12 months; the grafts were patent. Four patients (0.4%) required reintervention with angioplasty. ConclusionsMultivessel total arterial revascularization was performed using the left internal thoracic artery-right internal thoracic artery Y composite conduit via a left minithoracotomy and showed that it was safe and reproducible. The midterm outcomes have been good, and coronary angiograms showed widely patent grafts. This novel technique may help optimize minimally invasive coronary surgery and the use of bilateral internal thoracic arteries. Further, this technique has the potential for decreased morbidity, shorter hospital stay, cosmesis, and earlier return to active life.

Feasibility and efficacy of simultaneous off-pump coronary artery bypass grafting and esophagectomy in elderly patients.

IntroductionTo analyze the outcomes of off-pump coronary artery bypass grafting (OPCABG) and esophagectomy simultaneously for patients with coronary artery disease (CAD) and coexisting esophageal cancer.MethodsTwenty-two patients with CAD and coexisting esophageal cancer underwent combined surgical interventions were subjected to the study. OPCABG was performed first, followed by esophagectomy. All the corresponding data including clinicopathological characteristics and postoperative outcomes were all investigated.ResultsAll the combined procedures were performed successfully. The average number of grafts was 2.36. Tumors were located at the middle third of the esophagus in 5 patients, at the lower third of the esophagus in 8 patients, at the esophageal gastric junction (EGJ) in 9 patients, respectively. The operations were carried out through a left lateral thoracotomy approach in 21 patients while a median sternotomy and left lateral thoracotomy approach was used in 1 patient for his condition rapidly worsened. Postoperatively, pneumonia occurred in 4 patients (18.2%). During the follow-up, three patients died of cancer metastasis /recurrence (6, 18, 37 months) and one died of pneumonia (1 month). The cumulative 5 years survival rate is 52.9%.ConclusionsThe combined procedure of OPCABG and esophagectomy is a safe and effective treatment option for patients with severe CAD and esophageal cancer.

Extended Hair Transplant: Combination of Two Techniques

Background: The hair restoration surgery is performed as a ‘strip harvest’ surgery or ‘follicular unit extraction’. These two procedures can be combined in a single sitting to increase the number of hair. The study was conducted as to share the experience of both the procedures in a single session. Materials and methods: The study was conducted in a private hair restoration surgery clinic. Only the patients undergoing combined surgery, i.e., FUT and FUE in the same session, were included after informed consent. The procedure was performed under local anaesthesia. First of all, the area for FUE was marked and then the strip was marked after checking the vertical scalp mobility. An area of about 1 cm was left on either side of the wound margins and FUE was performed using 0.8–1.0 mm punch with a motorized machine. An antibiotic ointment was applied on the donor area. Oral antibiotics were prescribed for five days. Any complication arising in these patients was managed accordingly. Results: A total of 54 patients were included. The mean age of the patients was 34.2 years. The average number of grafts harvested was 3180.8 (range, 1022 to 4751). The average number of grafts harvested by FUT was 1763.5 (range, 333 to 2744). The average number of grafts harvested by FUE was 1417.3 (range, 110 to 2450). In majority of the patients more than 2500 grafts were harvested. Conclusion: Combining both the techniques increases the total number of grafts which results in patient satisfaction.

Comparison of miRNA signature versus conventional biomarkers before and after off-pump coronary artery bypass graft

Circulating levels of microRNAs (miRNAs) and their expression patterns are supposed to serve as signatures for diagnosis or prognosis of cardiovascular events. The present study aimed at determining if there is any correlation between the release pattern of 2 miRNAs and the plasma levels of conventional biomarkers cardiac troponin I (cTnI), creatine kinase (CK) and uric acid (UA) in patients undergoing their first off-pump coronary artery bypass graft (OCABG). Seventy OCABG patients (69% men, aged 59.2±8.2years) were enrolled. Emergencies, re-operations, abnormal preoperative serum cTnI and combined procedures were excluded from this study. Pre-operative mean ejection fraction was 45.8±8.6%, the average number of grafts was 3±0.87/patient, and the internal mammary artery was used for all. Beside conventional clinical assays, we performed real-time quantitative PCR to analyze the circulating levels of miR-155, miR-126 and miR-499 at 1day before surgery as well as 4days after surgery. Importantly, there was no report of myocardial infarction in our patients, pre- or post-operatively. In contrast to conventional biomarkers cTnI and CK, circulating levels of miRNAs decreased significantly (P<0.01) after revascularization surgery. A significant positive correlation was seen between the cTnI and miR-499 (r∼0.53, P<0.01) and between miR-126 and UA (r∼0.5, P<0.01). Time course study of circulating miR-499, miR-126 and miR-155 in cardiac surgery clarified their advantage and correlations to the traditional biomarkers cTnI, total CK, CK-MB and UA. Our results suggest that this signature is a novel, early biomarker which indicates myocardial ischemia in cardiac surgery. It could be postulated that the application of these miRNAs may be considered for monitoring of response to pharmacological interventions aimed at reducing cardiac ischemia, especially in OCABG candidates.

Operative risks and mid-term outcomes following offpump coronary artery bypass grafting at Christchurch Hospital

Introduction: Various randomised and non-randomised studies have been conducted to compare offpump versus standard onpump coronary artery bypass grafting (CABG). However a definitive conclusion regarding the relative merits of both surgical strategies is difficult to reach due to the nature of the study design, influenced by factors such as patient selection and the relative experience of surgeons performing offpump CABG. At Christchurch Hospital, two out of three surgeons perform isolated CABG using offpump techniques routinely in all patients. Our study sought to review the clinical outcomes of patients undergoing offpump CABG from an “all-comers” registry. Methods: All patients receiving offpump CABG at the Christchurch Hospital between January 2009 and March 2014 were identified. Baseline demographics, intra-operative data and clinical outcomes were reviewed. Results: Between January2009andMarch2014, 499patients underwent offpump CABG. Eighty-one percent of patients were male. The mean age was 70 years. The mean pre-operative New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) class were 1.4 and 2.8 respectively. Sixty-one patients (12%) had ejection fraction less than 35% and 195 (39%) had left main coronary stenosis >50%. The urgency of the operation were as follows: 19% (95/499) elective, 79.4% urgent (396/499) and 1.6% (8/499) emergency. The average number of grafts (distal anastomosis) performed was 3.6 and the average number of proximal anastomosis performed was 1.5. There was a higher rate of conversion to onpumpwith patients who had >50% left main disease (2.5% vs 0.3%, P<0.05). The conversion however is not associatedwith increased 30-daymortality andmorbidity nor themid-termmortality.Operativemortality analysis using the Society of Thoracic Surgeons (STS) predicted risk of mortality revealed a relatively low operative mortality even in moderately high risk patient group at our centre. Thirty-day outcomes are as shown in Table 1. At the latest follow-up (mean follow-up of 40 months), 469/499 (94%) patients are alive. Discussion: Offpump CABG at our centre is associated with low operative risks. The higher rate of conversion to onpump may be due to the nature of cardiac instability during manipulation; it is however not associated with increased mortality or morbidity. The low operative mortality in patients with high STS predicted risk of mortality suggest that offpump CABG at our centre has past the learning curve. It may also imply that offpump CABG may be better and safer for high risk patients.

Radio frequency Cox Maze procedure: A retrospective analysis of the initial 50 consecutive cases at a single institution

Introduction: Various randomised and non-randomised studies have been conducted to compare offpump versus standard onpump coronary artery bypass grafting (CABG). However a definitive conclusion regarding the relative merits of both surgical strategies is difficult to reach due to the nature of the study design, influenced by factors such as patient selection and the relative experience of surgeons performing offpump CABG. At Christchurch Hospital, two out of three surgeons perform isolated CABG using offpump techniques routinely in all patients. Our study sought to review the clinical outcomes of patients undergoing offpump CABG from an “all-comers” registry. Methods: All patients receiving offpump CABG at the Christchurch Hospital between January 2009 and March 2014 were identified. Baseline demographics, intra-operative data and clinical outcomes were reviewed. Results: Between January2009andMarch2014, 499patients underwent offpump CABG. Eighty-one percent of patients were male. The mean age was 70 years. The mean pre-operative New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) class were 1.4 and 2.8 respectively. Sixty-one patients (12%) had ejection fraction less than 35% and 195 (39%) had left main coronary stenosis >50%. The urgency of the operation were as follows: 19% (95/499) elective, 79.4% urgent (396/499) and 1.6% (8/499) emergency. The average number of grafts (distal anastomosis) performed was 3.6 and the average number of proximal anastomosis performed was 1.5. There was a higher rate of conversion to onpumpwith patients who had >50% left main disease (2.5% vs 0.3%, P<0.05). The conversion however is not associatedwith increased 30-daymortality andmorbidity nor themid-termmortality.Operativemortality analysis using the Society of Thoracic Surgeons (STS) predicted risk of mortality revealed a relatively low operative mortality even in moderately high risk patient group at our centre. Thirty-day outcomes are as shown in Table 1. At the latest follow-up (mean follow-up of 40 months), 469/499 (94%) patients are alive. Discussion: Offpump CABG at our centre is associated with low operative risks. The higher rate of conversion to onpump may be due to the nature of cardiac instability during manipulation; it is however not associated with increased mortality or morbidity. The low operative mortality in patients with high STS predicted risk of mortality suggest that offpump CABG at our centre has past the learning curve. It may also imply that offpump CABG may be better and safer for high risk patients.

Effects of on-pump and off-pump surgery in the Arterial Revascularization Trial.

The Arterial Revascularization Trial (ART) is a randomized comparison of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting in coronary artery bypass graft (CABG) surgery and is one of the largest randomized trials of surgery ever conducted. ART is also one of the largest studies of contemporary CABG with a high proportion of off-pump surgeries (41%). The objective of this post hoc analysis was to evaluate the surgical process and 1-year outcomes for surgery performed on-pump compared with off-pump. ART randomized 3102 patients with multivessel coronary artery disease (CAD) to SIMA or BIMA grafts to determine if BIMA grafts have an additional survival advantage at 10 years. The 1-year interim analysis showed an overall very low mortality and major morbidity rate irrespective of whether the procedure was with an SIMA or BIMA. The surgical process and 1-year outcomes were analysed according to whether surgery was performed on-pump or off-pump. Baseline variables were not statistically significantly different between on- and off-pump surgery within each treatment group after taking account of the effects of clustering by individual surgeons. At both 30 days and 1 year, there was a low incidence of death (1.2%, 2.3%), stroke (1.1%, 1.7%), myocardial infarction (MI) (1.4%, 1.9%), repeat revascularization (0.5%, 1.5%) and wound reconstruction (1.2%). A similar average number of grafts were performed with on- and off-pump surgery (median = 3), but the duration of surgery was 20-30 min and ventilation time ∼ 2 h shorter with off-pump surgery. Blood loss and platelet transfusions were lower in the off-pump group, with no difference in the need for balloon pump or renal support. Sternal wound reconstruction was similar with off-pump surgery in the SIMA group (0.5 vs 0.6%) and lower with off-pump surgery in the BIMA group (1.4 vs 2.2%). Repeat revascularization was marginally higher in off-pump patients at 30 days (0.8 vs 0.3%) and at 1 year (1.7 vs 1.3%). The outcomes of contemporary CABG are excellent with low mortality, stroke, myocardial infarction and need for wound reconstruction and repeat revascularization whether performed on-pump or off-pump. Controlled-trials.com (ISRCTN46552265).