Complete Surgical Revascularization Research Articles

Complete surgical myocardial revascularization in patients with declined renal functions: 12-month outcomes

IntroductionThis retrospective observational study aimed to evaluate the feasibility and effectiveness of complete revascularization coronary artery bypass grafting (CABG) in patients with multi-vessel disease (MVD)-CAD and declined renal functions, addressing the knowledge gap regarding optimal treatment strategies and outcomes in this specific patient population.MethodsBetween 2020 and 2022, a total of 58 patients underwent on-pump coronary artery bypass grafting surgery for complete myocardial revascularization in this study. To assess overall survival, Kaplan–Meier with the log-rank test was conducted for statistical analysis.ResultsThe mean age of cohort was 60.7. The findings showed a high prevalence of medical conditions such as hypertension (50.0%), diabetes (50.0%), and anaemia (41.4%) among the participants. Intraoperatively, low cardiac output syndrome was reported in 5.2% of cases, while perioperative outcomes indicated a need for transfusions in 53.5% of cases and an in-hospital mortality rate of 3.4%. At the 12-month follow-up, no redo revascularization or renal replacement therapy was required, but cardiac mortality was 5.2% and all-cause mortality was 6.9%.ConclusionsThe study concluded that complete revascularization is safe for these patients and highlights the potential benefits, emphasizing the need for further research in optimizing revascularization techniques for this population.

Complete surgical revascularization after NSTEMI and unstable angina in patients with multivessel coronary artery disease: Institutional experience.

The feasibility and standardization of coronary artery bypass grafting (CABG) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unstable angina (UA) remain topics of ongoing debate. In this study, feasibility and early-term outcomes of CABG in patients with NSTE-ACS and UA were discussed. This study enrolled 79 patients who underwent on-pump CABG with complete revascularization between January 2020 and May 2022. the survival rates analyzed using Kaplan Meier test with log rank test. The p value of statistical significance was taken as below 0.05. Preoperatively, the patients had a mean age of 60.9 years and a BMI of 28.0. The medical history included hypertension (50.6%), peripheral arterial disease and atrial fibrillation (12.7%), and other comorbidities such as COPD (22.8%) and type 2 diabetes mellitus (44.3%). Intraoperatively, the mean distal anastomosis count was 3.4, with average cardiopulmonary bypass and aortic cross-clamp times of 84.0 and 49.0 min, respectively. Early-term outcomes revealed low rates of mortality (2.5%) and complications such as myocardial infarction (1.3%), acute kidney injury (5.1%) and transient ischemic attack (5.1%). Post-discharge outcomes demonstrated low cardiac and all-cause mortality rates (2.5% and 3.8%, respectively) and a high overall survival rate (93.7%) at 12-month follow-up. This study demonstrated the feasibility and positive outcomes of complete surgical revascularization in patients with UA and NSTE-ACS. It showed no graft occlusion or stroke, low complication rates and promising survival outcomes. Further research is needed for confirmation and to establish the procedure's efficacy and safety in this patient population.

Long-term survival, cardiovascular, and functional outcomes after minimally invasive coronary artery bypass grafting in 566 patients

ObjectiveSternotomy has been the gold standard incision for surgical revascularization but may be associated with chronic pain and sternal malunion. Minimally invasive coronary artery bypass grafting allows for complete surgical revascularization through a small thoracotomy in selected patients. There is a paucity of long-term data, particularly functional outcomes, for patients who underwent minimally invasive coronary artery bypass grafting. MethodsPatients (N = 566) who underwent minimally invasive coronary artery bypass grafting at a single institution over a 17-year period were prospectively followed. The primary outcome was survival. At late follow-up, patients were contacted for a questionnaire on functional outcomes. Multivariable Cox proportional hazard model identified correlates of the primary outcome. ResultsClinical follow-up was complete for 100% of patients (mean 7.0 ± 4.4 years); a follow-up questionnaire was also completed for 83.9% (N = 427) of live patients. Fifty percent of patients (N = 283) had undergone multivessel grafting. At 12 years, survival for the entire cohort was 82.2% ± 2.6%. On late follow-up questionnaire, 12 patients (2.8%) had greater than Canadian Cardiovascular Score Class II angina and 19 patients (4.5%) had greater than New York Heart Association Class II symptoms. More than 98% of patients did not have pain related to the incision site. Cox proportional hazards analysis identified older age, peripheral vascular disease, prior myocardial infarction, left ventricular dysfunction, cancer in the past 5 years, intraoperative transfusion, and hybrid revascularization as correlates of mortality during follow-up. ConclusionsMinimally invasive coronary artery bypass grafting is a safe and durable alternative to sternotomy coronary artery bypass grafting in selected patients, with excellent short- and long-term outcomes, including for multivessel coronary disease. At long-term follow-up, the proportion of patients with significant symptoms and incisional pain was low.

Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease.

ObjectivesAlthough endorsed by international guidelines, complete revascularization (CR) with Coronary Artery Bypass Grafting (CABG) remains underused. In higher-risk patients such as those with pre-operative atrial fibrillation (AF), the effects of CR are not well studied.MethodsWe analyzed patients’ data from the HEIST (HEart surgery In AF and Supraventricular Tachycardia) registry. Between 2012 and 2020 we identified 4770 patients with pre-operative AF and multivessel coronary artery disease who underwent isolated CABG. We divided the cohort according to the completeness of the revascularization and used propensity score matching (PSM) to minimize differences between baseline characteristics. The primary endpoint was all-cause mortality.ResultsMedian follow-up was 4.7 years [interquartile range (IQR) 2.3–6.9]. PSM resulted in 1,009 pairs of complete and incomplete revascularization. Number of distal anastomoses varied, accounting for 3.0 + –0.6 vs. 1.7 + –0.6, respectively. Although early (< 24 h) and 30-day post-operative mortalities were not statistically different between non-CR and CR patients [Odds Ratio (OR) and 95% Confidence Intervals (CIs): 1.34 (0.46–3.86); P = 0.593, Hazard Ratio (HR) and 95% CIs: 0.88 (0.59–1.32); P = 0.542, respectively] the long term mortality was nearly 20% lower in the CR cohort [HR (95% CIs) 0.83 (0.71–0.96); P = 0.011]. This benefit was sustained throughout subgroup analyses, yet most accentuated in low-risk patients (younger i.e., < 70 year old, with a EuroSCORE II < 2%, non-diabetic) and when off-pump CABG was performed.ConclusionComplete revascularization in patients with pre-operative AF is safe and associated with improved survival. Particular survival benefit with CR was observed in low-risk patients undergoing off-pump CABG.

Complete surgical revascularization: Different definitions, same impact?

There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes. All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated. emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow-up complete in 100% patients; median 5.5; IQR: 4.4-6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long-term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes. Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226-0.969; p = .041). No other definitions showed effect on follow-up mortality. Age and cardiac dysfunction increased long-term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization CONCLUSIONS: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG.

Extracorporeal Membrane Oxygenation (ECMO) Rescue Therapy in Post-cardiotomy Cardiogenic Shock: A Case Report.

Cardiogenic shock is a constant challenge for the intensivist when complicating a myocardial infarction, due to the high rate of associated morbidity and mortality, especially in the setting of mechanical complications such as papillary muscle rupture.We present the case of a 49-year-old woman with cardiogenic shock due to acute myocardial infarction (AMI) complicated by severe mitral valve insufficiency due to papillary muscle rupture. She was treated initially by medical optimization, followed by mitral valve replacement and complete surgical revascularization, requiring rescue mechanical circulatory support by extracorporeal membrane oxygenation (ECMO).ECMO proved to be a rescue therapy in a patient with refractory cardiogenic shock after urgent cardiac surgery.

Features and hospital outcomes of coronary artery bypass grafting in patients with calcification of target coronary arteries

Aim. To compare strategy and early results of coronary artery bypass grafting (CABG) in patients with and without calcification of target coronary arteries (TCA).Material and methods. The prospective study analyzed the data of patients (n=462) who underwent elective isolated CABG in 2017-2018 using cardiopulmonary bypass and microsurgery. Two groups were distinguished: group 1 — patients with TCA calcification (n=108), group 2 — patients without TCA calcification (n=354). In cases where the distal coronary artery lesion did not allow standard bypass grafting, additional complex anastomoses were provided. A comparison of intraoperative parameters and early results of CABG was carried out.Results. In groups 1 and 2, the revascularization index did not differ significantly and was 4,5 and 4,3, respectively. The frequency of complex surgical interventions in group 1 was higher: for example, ‘Y’ grafts were used in groups 1 and 2, respectively, in 32% (35/108) and 12% (44/354), p&lt;0,05; sequential anastomoses in 14% (15/108) and 7% (26/354), p&lt;0,05; prolonged patch-angioplasty — in 21% (23/108) and 5% (16/354), p&lt;0,05; anastomoses with arteries &lt;1,5 mm in diameter — in 33% (36/108) and 4% (14/354), p&lt;0,05; coronary endarterectomy in 17% (18/108) and 5% (16/354), p&lt;0,05, respectively. The duration of cardiopulmonary bypass was longer in group 1. At the same time, the hospital clinical results did not differ significantly: mortality was not registered; the frequency of perioperative myocardial infarction was 1,8% (group 1) and 1,1% (group 2); the need for inotropes, frequency of arrhythmia, length of stay in the intensive care unit and hospital were similar; there were no cases of in-hospital angina recurrence.Conclusion. CABG in patients with calcification of TCA is associated with surgical challenges and need for complex adjunct techniques. Nevertheless, complete surgical revascularization is real in these cases, and the hospital results are comparable to those in patients without calcification.

Minimally invasive multivessel coronary bypass surgery: Angiographic patency data.

Minimally invasive multivessel coronary artery bypass grafting (MIM CABG) has demonstrated its safety, effectiveness and high rate of reproducibility. However, minithoracotomy CABG is still rarely performed. In this study, we retrospectively analyze the CT-angiographic graft patency rates for the patients subjected to this operation. A total of 245 patients were subjected to MIM CABG by a left minithoracotomy approach between 2014 and 2018. The left internal thoracic artery (LITA) harvesting, proximal, and distal anastomoses were performed under direct vision. The patients then underwent 128-slice computed tomography coronary angiography (CTA). The angiographic results were obtained for 127 (51.8%) patients (the follow-up period of 31.1 ± 7.8 months, from 15 to 45 months). Of the total patients, 204 (83.2%) were followed clinically during the time period from 12 to 56 months. Complete revascularization was performed for all the patients. The mean number of grafts was 2.6 ± 0.5. The perioperative mortality was 0.4% (1 patient). There were two conversions to sternotomy (0.8%), four reopenings for bleeding (1.6%), three myocardial infarctions (1.2%), and one stroke (0.4%). Twenty-two patients (9.0%) received transfusions. The long-term mortality was 4.4% (nine patients). Three patients (1.5%) suffered from a stroke during the follow-up period. For five patients (2.4%), repeat revascularization was necessary. For the examined patients, the overall graft patency rate was 89.8%, the LITA graft patency rate was 98.4%, the radial artery patency was 100%, and the saphenous vein graft patency was 84.0%. MIM CABG allows complete surgical revascularization with excellent clinical outcomes and promising angiographic graft patency rates.

P4737Complete surgical revascularization: the impact of the different definitions on mortality

Abstract Introduction The concept of complete revascularization arises from the early stages on coronary artery bypass grafting (CABG). There are several different definitions applied across the literature, promoting a difficult comparison between studies. Despite the established importance of complete revascularization, there is no agreement which definition has the most impact on mortality. Objectives Evaluate the impact of the different definitions of complete surgical revascularization in late mortality. Methods Single center retrospective study of all consecutive patients submitted to isolated CABG with previous myocardial viability assessment (myocardial perfusion scintigraphy) from 2011 to 2016. Exclusion criteria: emergent procedures and previous cardiac surgery. The primary end-point was follow-up mortality (n=20). The population of study was162 patients with 22,2% female gender and a mean age of 66 years. The follow-up was complete in 98,8%, median time of 4,1 (IQR 3,0–5,5) years. The completeness of revascularization was classified in all patients according to four different definitions (n=162 for each definition): Numerical (the number of stenotic vessels must equal the number of distal anastomoses applied); Functional (all ischemic myocardial territories are reperfused; areas of old infarction with no viable myocardium are not required to be reperfused); Anatomical Conditional (all stenotic main-branch vessels are revascularized) and Anatomical Unconditional (all stenotic vessels are revascularized, irrespective of size and territory supplied). For each definition, statistical analysis was performed using the Kaplan-Meier method with log rank test and Cox proportional analysis (EuroSCORE II and revascularization definition). Results On univariate analysis, there was no significant statistical association between each definition of complete revascularization and follow-up mortality: numerical (p=0,694); anatomical unconditional (p=0,294); but a trend was found on functional (p=0,063) and anatomical conditional (p=0,084). On multivariate analysis, incomplete functional revascularization increased the risk of follow-up mortality in 2,89 folds and anatomical conditional in 3,28 folds (Figure 1). The other definitions were not statistically associated with late mortality. Conclusion According to this study, complete functional and anatomical conditional revascularization definitions are determinants of follow-up mortality in a multivariate model including EuroScore II. The revascularization of all stenotic main-branch vessels (anatomical conditional) seems to have the highest impact, fact that we should be taken in consideration on daily work.

Complete surgical myocardial revascularization: shift of paradigm of the gold standard in the current era

Vessel Plus is an open acccess journal, which publishes articles related to vascular diseases, including acute respiratory distress syndrome, aneurysm, atherosclerosis, hypertension, stroke, peripheral vascular or pulmonary vascular diseases, etc.

100.58 Retrospective Comparison of Complete Surgical Revascularization vs. Hybrid Revascularization in Patients with Multivessel CAD

CABG is a proven strategy for revascularization in patients with left main or multi-vessel CAD. The SYNTAX trial showed similar outcomes between CABG and PCI when revascularizing low- and medium-complexity lesions. Hybrid revascularization consists of treating left anterior descending coronary

Identification of candidates for coronary artery bypass grafting admitted with STEMI and Multivessel Disease.

The optimal management of patients with multivessel coronary artery disease (MVD) admitted with STEMI is under debate. CABG is rarely performed, even on ideal candidates. A provisional PCI without stent implantation may allow complete surgical revascularization (CSR) in a subset of patient that we sought to identify in this study. Patients with STEMI from April 2014 to October 2016 were evaluated and those with a TIMI flow <3 in the culprit vessel, and an additional stenosis of >70% in an epicardial vessel or sidebranch >2.5 mm were selected. Epidemiological variables, surgical risk scores and SYNTAX and SYNTAX II scores were analyzed. All the selected patients were discussed in a post hoc heart-team, and predictors of 12-month events were also analyzed. Seventy-two (19.0%) accomplished MVD criteria. Mean SYNTAX was 19 ± 13 points and SYNTAX II score recommended CABG in 12 patients (16.7%) and heart-team discussion in 60 (83.3%). All patients were discussed in a post hoc heart-team, which concluded that 21 (29.2%) patients could have been good candidates for CSR. After one year follow-up, SYNTAX II PCI > 40 was found to be the sole independent predictor for 12-month events (OR 12.9 [2.7-62.1], p = 0.001). MVD and STEMI with a SYNTAX II PCI > 40 should be discussed in an ad-hoc heart team, after a provisional revascularization of the culprit vessel, and should be considered for CSR, especially when the RCA is the culprit artery and there is a complex disease in the left coronary artery.

CRT-100.53 Identification Of Candidates For Coronary Artery Bypass Grafting In Patients With Multivessel Disease Admitted With STEMI: A Single-center Descriptive Study

The management of multivessel coronary artery disease (MVD) in STEMI setting is under debate. Complete surgical revascularization with CABG is not usually considered due to the need for emergency revascularization of the culprit vessel, which is performed faster percutaneously. Many patients who are

Coronary Endarterectomy with off Pump Coronary Artery Bypass Surgery- A Review

Coronary endarterectomy is first described as an alternative surgical procedure for myocardial revascularization against diffuse coronary artery disease by Baily et al. in 1956. Coronary endarterectomy provides complete surgical revascularization of the myocardium in diffuse and calcified coronary arteries with adequate blood flow to distal part of occluded arteries, thus improving ventricular function. However, the initial outcomes of coronary endarterectomy were not satisfactory but now-a-days different studies have shown that coronary endarterectomy with coronary artery bypass grafting can be done safely with acceptable morbidity and mortality. Moreover, the graft patency rate on angiographic evaluation is also good following coronary endarterectomy. So, it’s time to reevaluate this old techniques, and reanalysis the current outcomes of coronary endarterectomy and readdress its indication in diffuse coronary artery diseaseCardiovasc. j. 2017; 10(1): 84-90

Emergency Off-Pump Coronary Artery Bypass Graft Surgery for Patients on Preoperative Intraaortic Balloon Pump

The aim of this study was to investigate early and long-term outcomes of patients with acute coronary syndrome preoperatively requiring intraaortic balloon pump support who underwent emergency off-pump coronary artery bypass graft surgery. One hundred and fifteen patients on preoperative intraaortic balloon pump receiving emergency off-pump coronary artery bypass graft surgery over an 11-year period were evaluated. The median age was 71 years (range, 33 to 87). Acute myocardial infarction and unstable angina were present in 54 patients (47.0%) and 61 patients (53.0%), respectively. Left main disease and triple-vessel disease without left main involvement were present in 74 patients (64.3%) and 33 patients (28.7%), respectively. There were 3 perioperative deaths. Complete surgical revascularization was accomplished in 82 patients (71.3%), and in situ internal thoracic artery graft was used in 96 (83.5%). Late survival, freedom from major adverse cardiac and cerebrovascular events, and freedom from repeat revascularization rates at 5 years were 83.3%, 73.5%, and 84.2%, respectively. The Cox multivariate prognostic predictors of total mortality were preoperative renal impairment (hazard ratio [HR] 7.90; 95% confidence interval [CI]: 3.06 to 20.4) and low ejection fraction (HR 0.94, 95% CI: 0.88 to 0.99). The multivariate risk predictors of major adverse cardiac and cerebrovascular events were preoperative renal impairment (HR 2.68, 95% CI: 1.00 to 7.19) and peripheral vascular disease (HR 2.81, 95% CI: 1.05 to 7.51), and complete revascularization was protective (HR 0.39, 95% CI: 0.19 to 0.81). The multivariate risk factor of repeat revascularization was previous percutaneous coronary intervention (HR 3.26, 95% CI: 1.14 to 9.33), and complete surgical revascularization was also protective (HR 0.30, 95% CI: 0.11 to 0.85). Off-pump coronary artery bypass graft surgery is a feasible option for patients requiring preoperative intraaortic balloon pump support.

Papillary Muscle Approximation Versus Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation

BackgroundGuidelines recommend surgery for patients with severe ischemic mitral regurgitation (MR). Nonrandomized studies suggest that subvalvular repair is associated with longer survival, but randomized studies are lacking. ObjectivesThis study sought to investigate the benefit of papillary muscle surgery on long-term clinical outcomes of patients with ischemic MR. MethodsNinety-six patients with severe ischemic MR were randomized to either undersizing restrictive mitral annuloplasty (RA) or papillary muscle approximation with undersizing restrictive mitral annuloplasty (PMA) associated with complete surgical myocardial revascularization. The primary endpoint was change in left ventricular end-diastolic diameter (LVEDD) after 5 years, measured as the absolute difference from baseline, which was evaluated by paired Student t tests. Secondary endpoints included changes in echocardiographic parameters, overall mortality, the composite cardiac endpoint (major adverse cardiac and cerebrovascular events [MACCE]), and quality of life (QOL) during the 5-year follow-up. ResultsAt 5 years, mean LVEDD was 56.5 ± 5.7 mm with PMA versus 60.6 ± 4.6 mm with RA (mean change from baseline −5.8 ± 4.1 mm and −0.2 ± 2.3 mm, respectively; p < 0.001). Ejection fraction was 44.1 ± 6% in the PMA group versus 39.9 ± 3.9% in the RA group (mean change from baseline 8.8 ± 5.9% and 2.5 ± 4.3%, respectively; p < 0.001). There was no statistically significant difference in mortality at 5 years, but freedom from MACCE favored PMA in the last year of follow-up. PMA significantly reduced tenting height, tenting area, and interpapillary distance soon after surgery and for the long-term, and significantly lowered moderate-to-severe MR recurrence. No differences were found in QOL measures. ConclusionsCompared with RA only, PMA exerted a long-term beneficial effect on left ventricular remodeling and more effectively restored the mitral valve geometric configuration in ischemic MR, which improved long-term cardiac outcomes, but did not produce differences in overall mortality and QOL.

Improved Wall Motion of Late Gadolinium-Enhanced Myocardium After Complete Surgical Revascularization

Gadolinium-enhanced cardiac magnetic resonance (CMR) imaging suggests a low possibility of myocardial function improvement after revascularization if the transmural extent of late gadolinium enhancement (LGE) was over 50%. We evaluated myocardial wall motion in patients who underwent complete revascularization for left ventricular dysfunction. Thirty-three patients with left ventricular dysfunction (ejection fraction ≤ 0.35) underwent complete revascularization. Gadolinium-enhanced CMR was performed preoperatively and postoperatively (postoperative 24.1 ± 17.6 months). Postoperative coronary angiograms were also performed to confirm graft patency. Wall motion score and transmural extent of LGE were evaluated on a 16 segment model of short-axis images. Of 528 total segments, 373 dysfunctional segments (70.6%; 189 hypokinesia, 177 akinesia, 6 dyskinesia, and 1 aneurysm) were evaluated for postoperative changes. When LGE was graded on a 5 point scale (absence of LGE, grade 0; LGE of 1% to 25%, grade 1; 26% to 50%, grade 2; 51% to 75%, grade 3; and 76% to 100%, grade 4), LGE was found in 221 (59%) segments (grades 1, n = 80; 2, n = 55; 3, n = 37; and 4, n = 49). After revascularization, wall motion improved in 72.1% (269 of 373) of dysfunctional segments (128 of 189 hypokinesia versus 141 of 184 akinesia; p = 0.055). Improved wall motion was observed in 77.0% (117 of 152), 67.5% (54 of 80), 69.1% (38 of 55), 86.5% (32 of 37), and 57.1% (28 of 49) of grades 0, 1, 2, 3, and 4 segments, respectively. Improved motion of late gadolinium-enhanced myocardium, even in segments showing transmural LGE of 75% or greater and akinesia, was observed after complete revascularization. An inverse proportional correlation between the transmural extent of LGE and wall motion improvement was not observed.

Minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting (MICS CABG) consists of single-vessel or multivessel revascularization via a small left thoracotomy, and has been proposed as an alternative to a standard sternotomy approach. The purpose of this article is to examine the current status of MICS CABG and discuss its future directions. Experience in the first 450 cases was reported in 2009, and established the efficacy and safety of a small thoracotomy approach for multivessel and single-vessel revascularization. In addition to earlier recovery and rehabilitation, MICS CABG is associated with fewer transfusions and fewer wound infections than off-pump CABG. Recently, the MICS CABG Patency Study showed excellent graft patency in patients assessed by 64-slice computed tomography angiography 6 months after operation. We also showed that the use of cardiopulmonary bypass assistance may help alleviate some of the learning curve inherent in this operation. MICS CABG has developed into a reproducible, high-quality, complete surgical revascularization alternative to conventional CABG. Preservation of sternal integrity allows patients to recover earlier, require fewer transfusions, and experience fewer infections. Further research on expanding the applicability of MICS CABG and enhancing its advantages over conventional CABG is warranted.

An open randomized controlled trial of median sternotomy versus anterolateral left thoracotomy on morbidity and health care resource use in patients having off-pump coronary artery bypass surgery: The Sternotomy Versus Thoracotomy (STET) trial

Our objective was to compare off-pump coronary artery bypass surgery carried out via a left anterolateral thoracotomy (ThoraCAB) or via a conventional median sternotomy (OPCAB). Recent advances in minimally invasive cardiac surgery have extended the technique to allow complete surgical revascularization on the beating heart via thoracotomy. Patients undergoing nonemergency primary surgery were enrolled between February 2007 and September 2009 at 2 centers. The primary outcome was the time from surgery to fitness for hospital discharge as defined by objective criteria. A total of 93 patients were randomized to off-pump coronary artery bypass surgery via a median sternotomy (OPCAB) and 91 to off-pump coronary artery bypass surgery via a left anterolateral thoracotomy (ThoraCAB). The surgery was longer for patients in the ThoraCAB group (median, 4.1 vs 3.3 hours) and there were fewer with more than 3 grafts (2% vs 17%). The median time from surgery to fitness for discharge was 6 days (interquartile range, 4-7) in the ThoraCAB group versus 5 days (interquartile range, 4-7) in the OPCAB group (P = .53). The intubation time was shorter, by on average 65 minutes, in the ThoraCAB group (P = .017), although the time in intensive care was similar (P = .91). Pain scores were similar (P = .97), but more analgesia was required in the ThoraCAB group (median duration, 38.8 vs 35.5 hours, P < .001; tramadol use, 66% vs 49%, P = .024). ThoraCAB was associated with significantly worse lung function at discharge (average difference, -0.25 L, P = .01) but quality of life scores at 3 and 12 months were similar (P = .52). The average total cost was 10% higher with ThoraCAB (P = .007). ThoraCAB resulted in no overall clinical benefit relative to OPCAB.

Iatrogenic Aortic Dissection … or Intramural Hematoma?

A 65-year-old black woman with hypertension and type 2 diabetes mellitus presented to her local hospital with acute chest discomfort. She had no history of connective tissue disease or family history of aortic catastrophes. An ECG showed inferior ST-segment elevation. Coronary angiography revealed multiple high-grade lesions in the right coronary artery (RCA) with evidence of thrombus (Movie I in the online-only Data Supplement). There were also critical stenoses in the left coronary system. Percutaneous coronary intervention of the RCA with 3 bare metal stents was successful in establishing Thrombolysis in Myocardial Infarction grade 3 flow, but deployment of the fourth stent was complicated by proximal RCA dissection with extension into the aortic sinuses (Figure 1 and Movie II in the online-only Data Supplement). Despite obliteration of the RCA dissection with the stent, persistent dye staining of the ascending aorta was present on final angiographic views (Figure 2). A computed tomography scan performed 2 days later showed an ascending aorta intramural hematoma (IMH;Figure 3). Plans were made for complete surgical revascularization in 6 weeks, and she was discharged. Aside from several brief episodes of chest discomfort in the first week after discharge, she remained asymptomatic. Three weeks after the initial event, the patient presented for a second opinion at our institution. Figure 1. Left anterior oblique angiographic view of the right coronary artery. An intracoronary guidewire (arrowhead) …