Patent Internal Mammary Artery Graft Research Articles

Comparative effectiveness of antiplatelet therapies for saphenous venous graft occlusion and cardiovascular outcomes: a network meta-analysis.

The ideal antiplatelet therapy to maintain graft patency after coronary artery bypass graft surgery (CABG) remains controversial. This review of randomized controlled trials (RCTs) aims to compare aspirin monotherapy, ticagrelor monotherapy, dual antiplatelet therapy (DAPT) with aspirin and ticagrelor (Asp+Tica) or with aspirin and clopidogrel (Asp+Clopi) to evaluate differences in post-CABG saphenous vein graft (SVG) occlusion, internal mammary artery (IMA) occlusion, myocardial infarction (MI), bleeding, and all-cause mortality (ACM) rates. The literature review was conducted on several electronic databases, including Medline, Embase, and Cochrane Central, from inception to August 10, 2022. Data was extracted using a predefined proforma. A Bayesian random-effects model was used for calculating point effect estimates (odds ratio and standard deviation). Quality assessment was done using the Cochrane RoB-2 tool. Ten RCTs comprising 2139 patients taking anti-platelets post-CABG were included. For preventing SVG occlusion, Asp+Tica showed the lowest mean AR of 0.144±0.068. Asp+Tica also showed a trend toward lesser postoperative MI risk and lower ACM rates, with a mean AR of 0.040±0.053 and 0.018±0.029, respectively. For maintaining IMA graft patency, Asp+Clopi showed the lowest mean AR of 0.092±0.053. Ticagrelor had the lowest mean AR of 0.049±0.075, with Asp+Tica showing a similar mean AR of 0.049±0.045 for postoperative major bleeding risk. Our analysis demonstrates that Asp+Tica can be the ideal therapy for patients undergoing CABG using SVG as it decreases the risk of post-CABG SVG occlusion and is not associated with a significantly higher risk for major bleeding.

Impact of Preoperative Quantitative Flow Ratio of the Left Anterior Descending Artery on Internal Mammary Artery Graft Patency and Midterm Patient Outcomes After Coronary Artery Bypass Grafting.

Background In coronary artery bypass grafting, grafting a target vessel with nonsignificant stenosis increases the risk of graft failure. The present study aims to investigate the impact of preoperative quantitative flow ratio (QFR), a novel functional assessment of the coronary artery, on internal mammary artery graft failure rate and midterm patient outcomes. Methods and Results Between January 2016 and January 2020, we retrospectively included 419 patients who underwent coronary artery bypass grafting who had received preoperative angiography and postoperative coronary computed tomographic angiography in our center. QFR of the left anterior descending (LAD) artery was computed based on preoperative angiograms. The primary end point was the failure of the graft on the LAD artery assessed by coronary computed tomographic angiography at 1 year, and the secondary end point was major adverse cardiac and cerebrovascular events including death from any cause, myocardial infarction, stroke, or repeat revascularization. Grafts on functionally nonsignificant LAD arteries (QFR >0.80) had a significantly higher failure rate than those on functionally significant LAD arteries (31.4% versus 7.2%, P<0.001). QFR outperforms degree of stenosis in discriminating graft failure (C statistic, 0.76 versus 0.58). Clinical follow-up (3.6 years, interquartile range [3.3-4.1]) was accomplished in 405 patients, and the rate of major adverse cardiac and cerebrovascular events was significantly higher among patients with functionally nonsignificant LAD arteries (10.1% versus 4.2%; adjusted hazard ratio, 3.08 [95% CI, 1.18-8.06]; P=0.022). Conclusions In patients receiving internal mammary artery to LAD artery coronary artery bypass grafting, preoperative QFR of the LAD artery of >0.80 was associated with a higher graft failure rate at 1 year and worse patient outcomes at the 3.6-year follow-up.

Long-term observational angiographic patency and perfect patency of radial artery compared with saphenous vein or internal mammary artery in coronary bypass surgery

ObjectivesIt is uncertain if the long-term biological behavior of the radial artery as a conduit for coronary bypass surgery has a similar resistance to the development of atherosclerosis as for the internal mammary artery. We aimed to examine long-term angiographic patency and disease-free patency (perfect patency) for internal mammary artery, radial artery, and saphenous vein grafts. MethodsA retrospective, single-center, individual patient cohort study of angiographic observations from patients' latest postoperative angiogram from 1997 to 2020 was performed. Analysis was per anastomosis and assessed for patency and perfect patency. A generalized linear mixed model premised upon logistic regression was used to minimize confounding bias. ResultsA total of 983 patients with 3064 grafts were included, with a median follow-up of 8.6 (interquartile range, 4.4-12.6) years after the operation. Multivariable analysis revealed differences for radial (patency, 86.9%; perfect patency, 86.4%) and internal mammary artery (patency, 93.9%; perfect patency, 93.5%) versus saphenous vein graft (patency, 72.8%; perfect patency, 46.2%). There were no differences between the 2 arterial conduits for patency (odds ratio, 1.40; 95% CI, 0.85-2.33; P = .189) and perfect patency (odds ratio, 1.14; 95% CI, 0.71-1.84; P = .578). If a conduit was patent, then 99.4% of radial artery, 99.6% of internal mammary artery, and 63.5% of saphenous vein graft were reported as perfectly patent. ConclusionsRadial artery and internal mammary artery had similar patency and perfect patency while both were superior to saphenous vein graft.

Instantaneous wave free ratio value impact on left internal mammary artery graft patency.

To assess whether instantaneous wave - free ratio (iFR) value is associated with left internal mammary artery (LIMA) graft failure at 12months follow-up post coronary artery bypass graft (CABG). Data suggests bypass to a non-significant left anterior descending artery (LAD) lesion due to visual over-estimation may lead to LIMA graft failure. Implementing iFR may result in better arterial graft patency. In iCABG (iFR guided CABG) study patients planned to undergo an isolated CABG procedure was prospectively enrolled and iFR was performed for LAD. Coronary computed tomography angiography was performed at 2 and 12months follow-up. The primary endpoint of this study was to determine the rate of LIMA graft occlusion or hypoperfusion at 2 and 12-months follow-up. We considered a composite secondary endpoint of Major adverse cardiovascular and cerebrovascular event (MACCE) as a secondary outcome. In total 69 patients were included with no differences regarding age, sex and risk factors. At 2months, 50 of LIMAs with pre-CABG iFR median 0.855 (0.785 - 0.892) were patent. Hypoperfusion was found in 8 LIMAs (median iFR 0.88 (0.842 - 0.90)). While, 7 LIMAs (median iFR 0.91 (0.88 - 0.96)) were occluded (p = 0.04). At 12months, when iFR of LAD was >0.85: just 12 (31.6% out of all patent LIMAS) grafts were patent and 24 (100.0% out of all hypoperfused/occluded) grafts were hypoperfused or occluded (p < 0.001). In terms of MACCE, no difference (p = 1.0) was found between all 3 groups divided according to iFR value. Instantaneous wave - free ratio value above 0.85 in LAD is a powerful tool predicting LIMA graft failure at 1-year follow up period.

Robotic Off-Pump Totally Endoscopic Coronary Artery Bypass in Patients With Low Ejection Fraction.

Objective: Robotic totally endoscopic coronary bypass (R-TECAB) has been shown to be a safe and effective technique with excellent outcomes. The aim of this study is to assess the feasibility of R-TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes with up to 7-year follow-up. Methods: All patients undergoing R-TECAB at our institution between July 2013 and July 2020 were retrospectively reviewed. A total of 100 patients were identified with low LVEF defined as ≤40%. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results were reviewed. Results: The mean LVEF was 31%, and 62% of all patients had preexisting congestive heart failure. Of the cohort, 59% had 3-vessel disease and 6% underwent previous cardiac surgery. Multivessel TECAB was performed in 54%. Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass, and 35% were extubated in the operating room. No sternotomy conversions were required. One patient underwent reoperation for bleeding. No perioperative stroke, myocardial infarction, or mortality occurred. The left internal mammary artery graft patency was 97% at a mean of 1.6 months in the staged hybrid percutaneous coronary intervention group. At midterm follow-up the cardiac-related mortality was 5%. Heart transplant or left ventricular assist device was required in 4 patients, and 1 patient experienced a myocardial infarction. Freedom from major adverse cardiac events was 89%. Conclusions: Off-pump TECAB can be successfully performed in patients with low LVEF in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and midterm outcomes.

Skeletonized vs Pedicled Internal Mammary Artery Graft Harvesting in Coronary Artery Bypass Surgery

The relative safety and patency of skeletonized vs pedicled internal mammary artery grafts in patients undergoing coronary artery bypass graft (CABG) surgery are unknown. To investigate the association of skeletonized vs pedicled harvesting with internal mammary artery graft patency and clinical outcomes 1 year after CABG surgery. This study was a post hoc analysis of the multicenter, randomized, double-blind, placebo-controlled Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) clinical trial, which enrolled 27 395 patients from 602 centers in 33 countries from March 2013 through May 2016. Eligibility criteria for the trial included CABG surgery for coronary artery disease with at least 2 grafts implanted and an estimated glomerular filtration rate of at least 30 mL/min. A total of 1002 of 1448 patients were randomized to the CABG arm of the COMPASS trial and underwent skeletonized (282 [28.1%]) or pedicled (720 [71.9%]) internal mammary artery harvesting. The patients had evaluable angiography results 1 year after surgery. Data were analyzed from October 11, 2019, to May 14, 2020. Patients underwent graft harvesting with either the pedicled technique or skeletonized technique. The primary outcome was graft occlusion 1 year after CABG surgery, as assessed by computed tomography angiography. A total of 1002 patients underwent skeletonized (282 [28.1%]; mean [SD] age, 65.9 [8.1] years; 229 men [81.2%]; 194 White patients [68.8%]) or pedicled (720 [71.9%]; mean [SD] age, 64.8 [7.6] years; 603 men [83.8%]; 455 White patients [63.2%]) internal mammary artery harvesting. Rates of internal mammary artery graft occlusion 1 year after CABG surgery were higher in the skeletonized group than in the pedicled group (33 of 344 [9.6%] vs 30 of 764 [3.9%]; graft-level adjusted odds ratio, 2.41; 95% CI, 1.39-4.20; P = .002), including the left internal mammary artery to left anterior descending artery (21 of 289 [7.3%] vs 25 of 725 [3.4%]; graft-level adjusted odds ratio, 2.10; 95% CI, 1.14-3.88, P = .02). After a mean follow-up of 23 months, skeletonized graft harvesting was also associated with a higher rate of major adverse cardiovascular events (20 [7.1%] vs 15 [2.1%]; adjusted hazard ratio, 3.19; 95% CI, 1.53-6.67; P = .002) and repeated revascularization (14 [5.0%] vs 10 [1.4%]; adjusted hazard ratio, 2.75; 95% CI, 1.10-6.88; P = .03). This post hoc analysis of the COMPASS randomized clinical trial found that harvesting of the internal mammary artery during CABG surgery using a skeletonized technique was associated with a higher rate of graft occlusion and worse clinical outcomes than the traditional pedicled technique. Future randomized clinical trials are needed to establish the safety and patency of the skeletonized technique. ClinicalTrials.gov Identifier: NCT01776424.

Patency of conduits in patients who received internal mammary artery, radial artery and saphenous vein grafts

BackgroundWhere each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period.MethodsResearch protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or “string sign” conduits. Perfect patency was present in patent grafts if there was no lumen irregularity.ResultsFifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P < 0.001. Patency RA 93.5% was also not different to IMA 96.8%, P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032.When both arterial conduits were combined, perfect patency, P < 0.001, and patency, P = 0.017, were superior to SVG.ConclusionsAll but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perfect patency and overall patency compared to saphenous vein grafts.

Coronary artery revascularization in infants, children, and adolescents: The internal mammary artery is still the conduit of choice.

In infants, children, and adolescents, the most common indication for coronary artery bypass graft surgery (CABG) has been Kawasaki disease or acquired familial hypercholesterolemia. However, pediatric CABG is now more commonly performed for coronary artery injuries which occur during or following arterial switch operations (ASO), the ross procedure, and tetralogy of Fallot repairs (TOF).1-3 CABG has also been performed in adults who present with acquired coronary atherosclerotic disease and have congenital lesions such as TOF.4 In adult CABG surgery, the internal mammary artery (IMA) is the conduit of choice because of its superior long-term patency. However, in infants, children, and adolescents, concerns have been raised regarding the use of the IMA because of competitive flow, the smaller diameter of the IMA, the size of the target vessel, the need for the IMA to provide the entire blood supply for large areas of the myocardium, and the potential of the IMA for somatic growth. In this edition of the Journal, Arnaz et al5 report their experience with CABG surgery in 10 children ranging from 88 days to 15 years. The indications for CABG included complications related to the ASO and the Ross procedure and iatrogenic injuries due to the anomalous location of coronary arteries during TOF repairs. Three patients died during the postoperative period, but none of the deaths were due to coronary ischemia. Eight patients received an IMA graft and two patients received saphenous vein grafts. Four of the eight IMA grafts underwent follow-up angiograms which showed patent IMA grafts in all patients. In two of these patients, the IMA grafts showed somatic growth after 9.5 and 18 years. None of the surviving seven patients had any recurrent angina, new Q waves, or a reduction in ejection fraction. Although the number of patients in this series is small, it confirms the results of other studies which have demonstrated that the IMA has excellent long-term patency and adapts well to somatic growth.6-8 Concerns regarding excessive stretching of the IMA as the children grow older have not materialized. Furthermore, the IMA's blood flow has been more than adequate to meet the demands of the myocardium in these younger patients. Arnaz et al5 have reaffirmed that the IMA can be successfully utilized in infants, children, and adolescents during complex procedures, even when emergent revascularization is necessary, and should be the conduit of choice in these young patients.

Non-manipulation of Patent LIMA in the Setting of Reoperative Aortic Valve Replacement in Patients with Previous Coronary Artery Bypass

A patent left internal mammary artery (LIMA) graft challenges the protective effects of cold blood cardioplegia in patients undergoing re-operative aortic valve replacement (AVR).

One-year clinical and angiographic results of hybrid coronary revascularization

ObjectiveTo evaluate 1-year clinical and angiographic results after hybrid coronary revascularization (HCR) combining off-pump left internal mammary artery (LIMA) grafting through an inferior J-hemisternotomy with percutaneous coronary intervention (PCI). MethodsProspective, single-arm clinical feasibility study including 100 consecutive patients with multivessel disease undergoing staged HCR. The primary endpoint was the major adverse cardiac and cerebrovascular event rate at 1 year. Secondary endpoints included 1-year all-cause death, stroke, myocardial infarction, repeat revascularization, and angiographic graft and stent patency. ResultsOne-year clinical follow-up data were available in all patients. The primary endpoint was met by 20 patients (20%). Individual endpoints were as follows: 1 death due to heart failure; 1 stroke, 2 procedure-related myocardial infarctions; and 1 spontaneous myocardial infarction during follow-up. A total of 16 patients underwent repeat revascularization: 5 surgical reinterventions during the index hospitalization for angiographically suspected internal mammary artery graft dysfunction, and 3 repeat PCIs. Only 1 patient had evidence of ischemia. After discharge, PCI was performed in 6 patients who had recurrent angina, and in 2 asymptomatic patients who had angiographic restenosis. At the 1-year angiographic follow-up, 87 of 89 (98%) patients had patent internal mammary artery grafts. Angiographic restenosis was present in 10 of 100 lesions treated by PCI. ConclusionsAngiographically controlled HCR was associated with a high repeat revascularization rate. The 1-year 98% LIMA-graft patency rate, and low risk of death and stroke, seem promising for the long-term outcome. Non–left anterior descending coronary artery lesion revascularization remains a challenge.

First-time, isolated surgical aortic valve replacement after prior coronary artery bypass surgery: results from the RECORD multicenter registry.

This multicenter study was undertaken to determine the immediate and long-term outcomes in patients undergoing a primary surgical aortic valve replacement (AVR) who had a previous coronary artery bypass graft surgery with patent grafts. One hundred and thirteen consecutive patients (mean EuroSCORE II, 10.3 ± 7.7%, median 8.0%) who underwent first-time isolated AVR after coronary artery bypass grafting (CABG) were the subjects of this multicenter study. The procedure was performed through a full sternotomy in 95.7% of cases, a patent internal mammary artery graft was clamped in 76.6% of patients. The temperature of cardioplegia was ≤12 °C in 62.8% of patients and systemic temperature was <32 °C in 23.9% of patients. Thirty-day mortality was 4.4%. Stroke was observed in 8.0% of patients, low cardiac output syndrome in 14.1%, prolonged tracheal intubation in 20.8%, and intensive care unit stay was longer than five days in 19.5% of patients. Among patients with a patent internal mammary graft (91 patients), clamping of this graft (5.7% vs. 0%, p = 0.57) was associated with a nonsignificant trend toward increased 30-day mortality. One-, three- and five-year survival rates were 91.5%, 90.4%, and 88.4%, respectively. Patients undergoing isolated AVR after prior CABG have a good immediate and late survival. A history of prior CABG should not be considered an absolute indication for transcatheter AVR.

Computed tomographic imaging in planning redo cardiac surgery after coronary bypass grafting - a roadmap to safety.

Patent coronary artery bypass grafts are at risk of injury during redo cardiac surgery. In particular, damage to a patent left internal mammary artery (LIMA) graft during repeat surgery is a well-described and potentially lethal complication [1]. Precise anatomical information is important for planning the surgical approach in reoperative cardiac surgery. The standard preoperative work-up including coronary angiography and chest X-ray may provide unsatisfactory information about the exact anatomical location of grafts [2]. This case report illustrates the value of preoperative computed tomography angiography (CT angiography) in patients undergoing repeat cardiac surgery after prior aortocoronary bypass surgery.

Transthoracic Doppler echocardiography of the left internal mammary artery graft

Assessment of the left internal mammary artery (LIMA) graft patency currently requires invasive investigation through coronary angiography. In the last years the successful application of noninvasive Doppler spectrum analysis has been reported for patency assessment of the LIMA graft after myocardial revascularization. Echocardiography is considered to be a sensitive noninvasive screening modality to diagnose critical narrowing of LIMA grafts and angiography should be reserved for cases in which Doppler echocardiography fails to visualize the LIMA or reveals an abnormal flow pattern.

Alternative Access in Transcatheter Aortic Valve Implantation: Brachiocephalic Artery Access

Direct ascending aortic access is an accepted alternative approach for transcatheter aortic valve implantation (TAVI) that can be preferred in case of excessive atherosclerosis or small caliber of femoral and subclavian vessels or after previous coronary artery bypass grafting with a patent left internal mammary artery graft. However, not all patients are suitable for this direct aortic approach. In these patients, we now use direct access through the brachiocephalic artery. The direct brachiocephalic access can be obtained with or without partial upper sternotomy, depending on the anatomy, which should be evaluated by preprocedural angiographic computed tomography scan. During the procedure, the cerebral tissue oxygen saturation is continuously monitored. We treated two patients with severe aortic valve stenosis, classified as not suitable for surgical aortic valve replacement, by means of TAVI through the brachiocephalic artery. Both patients had excessive iliac atherosclerotic disease. One had patent left internal mammary artery and venous grafts after previous coronary artery bypass grafting so the femoral, direct aortic, nor left subclavian access was suitable; the other had a severely atheromatous and calcified aorta. No procedural or late complications were seen. If transfemoral, subclavian, and direct aortic accesses for TAVI are contraindicated, the direct brachiocephalic access seems to be a safe and feasible alternative.

Coronary Computed Tomographic Angiography for Prediction of Procedural and Intermediate Outcome of Bypass Grafting to Left Anterior Descending Artery Occlusion With Failed Visualization on Conventional Angiography

Conventional coronary angiography (CCA) has considerable limitations regarding visualization of distal vessel segments in chronic total occlusion. We assessed the ability of coronary computed tomographic angiography (CCTA) to predict the success of coronary artery bypass grafting (CABG) to the chronically occluded left anterior descending coronary artery (LAD) incompletely visualized on CCA. Thirty symptomatic patients rejected for CABG on the basis of the CCA findings underwent preoperative CCTA before intended transmyocardial laser revascularization. The LAD was explored operatively in all patients, and CABG to the LAD was attempted if the distal vessel was suitable for anastomosis. The procedural outcome of CABG and the 6-month patency of the left internal mammary artery graft at follow-up CCTA were defined as the primary and secondary end point, respectively. The primary and secondary end points were achieved in 80% and 77% of patients, respectively. We found a significant correlation between the intraoperative and computed tomographic measurement of distal LAD diameter (R = 0.428, p = 0.037). On multivariate analysis, the maximum diameter of the distal LAD by CCTA (odds ratio 8.16, p = 0.043) was the only independent correlate of procedural success of CABG. A cutoff value of 1.5 mm for the mean distal LAD diameter predicted left internal mammary artery graft patency with 100% specificity and 83% sensitivity. Successful CABG resulted in significant improvements in angina class and left ventricular function in LAD segments at 6 months of follow-up. In conclusion, CCTA predicted both the procedural and the intermediate outcome of CABG to chronic LAD occlusion with failed visualization on CCA.

Coronary Subclavian Steal Syndrome Unamenable to Angioplasty Successfully Managed with Subclavian-Subclavian Bypass

Purpose. Coronary-subclavian steal syndrome (CSSS) is defined as a reversal of flow in a previously constructed internal mammary artery (IMA) coronary conduit, producing myocardial ischemia. We present a case of CSSS which could not be ameliorated with endovascular therapy and necessitated a subclavian-subclavian bypass. Case Report. 80-year-old Caucasian male with history of CABG presented with syncope. He had absent left-sided radial pulse with blood pressure being 60/40 on left arm and 130/80 on the right. He underwent cardiac catheterization for NSTEMI which showed patent left internal mammary artery graft to left anterior descending coronary artery with retrograde flow, and diagnosis of coronary subclavian steal syndrome was made. Complete occlusion of proximal left subclavian artery was identified. Percutaneous angioplasty failed because of calcified plaque causing 100% occlusion. Carotid doppler showed bilateral carotid artery disease. He finally underwent subclavian-subclavian bypass which resolved his condition. Conclusion. Subclavian-subclavian bypass is a successful alternative to carotid-subclavian bypass for management of CSSS especially with concomitant critical carotid artery atherosclerotic disease.

Multimodality imaging guides management of an enlarging saphenous vein graft aneurysm

A 57-year-old man presented with chest pain and inferior ST-segment depression. Seven years previously, he had undergone coronary artery bypass surgery. Coronary angiography revealed a patent left internal mammary artery graft, occluded saphenous vein graft (SVG) …

Systemic hyperkalemia and mild hypothermia for valve surgery in patients with patent internal mammary artery graft

Myocardial protection is compromised in patients with a patent internal mammary artery (IMA) graft. We assessed the advantages of systemic hyperkalemia with mild hypothermia for valve surgery in patients with a patent IMA graft. Nine patients (mean age 71.5+/-7.0 years) with a patent IMA graft underwent valve surgery from May 2004 to July 2009. Of those, eight underwent aortic valve replacement and one mitral repair, with two double-valve surgery. Antegrade and retrograde blood cardioplegia were performed intermittently, and systemic potassium was given to all. The lowest bladder temperature was 27.2+/-2.4 degrees C, and the initial and peak systemic potassium levels were 6.8+/-1.4 and 8.0+/-1.6 mEq/l, respectively, while potassium at the end of the cardiopulmonary bypass procedure after sufficient modified ultrafiltration was reduced to 5.5+/-0.6 mEq/l. There was one hospital death due to ischemic colitis. Cardiac arrest was easily achieved in each patient without IMA or aortocoronary graft injury. The postoperative peak creatine kinase-MB level was 33+/-17 IU/l, with no ST changes seen in electrocardiogram findings or new asynergy seen in echocardiogram findings. Systemic hyperkalemia and mild hypothermia for valve surgery in patients with a patent IMA graft is a good option to reduce graft and myocardial injuries.

Aortic distensibility and coronary artery bypass graft patency

BackgroundAortic distensibility is an elasticity index of the aorta, and reflects aortic stiffness. Coronary artery disease has been found to be substantially associated with increased aortic stiffness. In this study we aimed to retrospectively analyze the association of angiographically determined aortic distensibility with the patency rates of coronary bypass graftsMethodsThe study was conducted in the Cardiology department of the Applied Research Centre for Health of Uludağ University. The coronary angiograms of 53 consecutive coronary bypass patients were analysed retrospectively. Aortic distensibility was calculated using the formula: 2 × (change in aortic diameter)/(diastolic aortic diameter) × (change in aortic pressure). The number of stenosed and patent bypass grafts and the patient characteristics like age, risk factors were noted.ResultsThere were 44 male (83%) and 9 female (17%) cases. Eighteen cases had only one saphenous vein grafting. The number of cases with two, three and four saphenous grafting were 18, 11 and 1; respectively. In the control angiograms the number of cases with one, two, three and four saphenous vein graft obstruction were 15 (31.3%), 7 (14.6%), 1 (2.1%) and 1 (2.1%) respectively. The aortic distensibility did not differ in cases with and without saphenous graft occlusion (p > 0.05). Also left internal mammary artery (LIMA) graft patency was not related to the distensibility of the aorta (p > 0.05). We also evaluated the data for cut-off values of 50 and 70 mmHg of pulse pressure and did not see any significant difference between the groups in terms of saphenous or LIMA grafts.ConclusionIn this study we failed to show association of angiographically determined aortic distensibility with coronary bypass graft patency in consecutive 53 patients with coronary artery bypass graft surgery (CABG).

Aortic Valve Replacement Following Coronary Artery Bypass Grafting Using Bilateral Internal Mammary Arteries

Aortic valve replacement in patients with a patent internal mammary artery grafts poses two main challenges: Sternal reentry and myocardial protection. Beating heart procedures have been well described in coronary and valve surgery. Herein, we describe a simple reproducible technique of aortic valve replacement that circumvents the main issues highlighted above.