Right Internal Mammary Artery Research Articles

Dual inflow, total-arterial, anaortic, off-pump coronary artery bypass grafting: how to do it.

Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein carries two main potential drawbacks: the known failure rate of vein grafts and the relatively high rate of neurologic injury. To address these concerns, we describe a technique that achieves complete revascularization without manipulating the ascending aorta (anaortic, off-pump) and utilizing total arterial grafts. All patients undergo thorough preoperative investigation, including bilateral carotid, vertebral and subclavian artery Duplex ultrasounds. A pulmonary artery catheter, transoesophageal echocardiography, and point-of-care coagulation testing are used in each case. The left and right internal mammary arteries and non-dominant radial artery are harvested using a fully skeletonised technique. Wide bilateral extrapleural retrothymic tunnels are developed and the pericardium is opened widely to facilitate cardiac positioning. A tandem graft is constructed with the right internal mammary artery (RIMA) in situ and radial artery using an end-to-end anastomosis. This graft is brought into the pericardium and through the transverse sinus in order to graft the lateral and inferior walls with multiple sequential distal anastomoses. The left internal mammary artery (LIMA) in situ is used to graft the anterior wall. Four main cardiac positions (high and low lateral walls, inferior and anterior walls) are obtained using a combination of off-pump stabilizer positioning, alternate tension on pericardial 'heart-strings', table tilting and folded wet sponges. All distal anastomoses are performed using silastic intracoronary shunts and an off-pump myocardial stabilizer. All grafts are checked using transit-flow time measurements. Milrinone is continued overnight and dual antiplatelet therapy is continued for 3 months postoperatively.

Mid-term graft patency of right versus left internal mammary artery as arterial conduit usage for left anterior descending artery revascularisation: Insights from a single-centre study of propensity-matched data

BackgroundPrevious studies reported the strategy of in situ skeletonised right internal mammary artery (RIMA) grafting to the left anterior descending artery (LAD). However, few reports have focused on assessing RIMA graft patency rate after grafting to the LAD. This study aimed to assess mid-term graft patency of in situ skeletonised RIMA grafting to the LAD versus in situ skeletonised left internal mammary artery (LIMA) grafting to the LAD in a single-centre propensity-matched study. Materials and methodsAfter propensity score matching, 185 pairs of patients who received first, scheduled, isolated off-pump coronary artery bypass grafting (OPCAB) surgery were assigned to either a RIMA group (patients who received retrosternal crossover in situ skeletonised RIMA-LAD grafting with additional conduits grafting) or a LIMA group (patients who received in situ skeletonised LIMA-LAD grafting with additional conduits grafting). The primary endpoint was mid-term internal mammary artery (IMA) graft failure after grafting to the LAD and was determined by coronary computed tomography angiography examination. The secondary endpoints were mid-term all-cause mortality and the composite mid-term clinical outcome. ResultsThe graft patency rate of in situ skeletonised RIMA-LAD graft was not inferior to in situ skeletonised LIMA-LAD graft during a follow-up period of 36.6 ± 12.1 months (97.2% vs. 96.6%, p = 0.752). Kaplan-Meier curves showed a similar cumulative IMA graft failure between the two groups (χ2 = 0.092, Log-rank p = 0.762). And Cox regression analysis revealed that grouping was not an independent factor for follow-up IMA graft failure after grafting to the LAD (HR = 0.93, 95% CI: 0.68–2.13). Additionally, Kaplan-Meier curves showed similar cumulative survival free from adverse events between the two groups (χ2 = 2.365, p = 0.124, respectively). ConclusionsRevascularisation of the LAD using a skeletonised RIMA resulted in excellent mid-term graft patency and clinical outcomes.

Cirugía coronaria con doble arteria mamaria: nuestra experiencia inicial y resultados a corto plazo

IntroductionBilateral internal mammary grafting (BIMA) in coronary bypass surgery (CABG) improves survival and recurrence of symptoms. There is still controversy regarding complications arising from its use and graft configuration strategy. We expose the short-term outcomes of BIMA grafting in our institution, as well as the different graft configurations available. MethodsPatients who underwent CABG with BIMA grafting between January 2011 and December 2015 were analyzed. Results413 (53.4%) out of 767 CABG patients underwent BIMA grafting. Mean age was 64 (SD: 8.7) years, with a 87.7% male. Mean EuroSCORE II was 2.7%. Three hundred and forty-nine patients (85.1%) underwent off-pump CABG. BIMA grafting with composite T-graft configuration was performed in 250 patients (60.5%), BIMA in situ grafting in 142 (34.3%) and BIMA grafting with free right internal mammary artery (RIMA) from the aorta, 21 patients (5.1%).30-day mortality (0.7%). Six patients (1.4%) needed BCIA for low cardiac output, five presented sternal wound infection (1.2%) or mediastinitis (1.2%), three stroke (0.7%), two patients (0.5%) had renal failure with hemodialysis and four (1%) needed re-operation for bleeding. ConclusionsBIMA grafting is a safe technique with excellent short term outcomes. Large prospective randomized trials with long term follow-up are still needed to clarify the optimal surgical strategy for graft configuration.

Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting.

Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used. In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts. From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years. Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.

Perceval S and Coronary Artery Bypass Grafting, Contradiction or Full Harmony?

Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, female 35,7%. Cardiovascular risk factors: Hypertension 97,6%; Diabetes 38,1%, Dyslipidemia 69%, peripheral vascular disease 38,2%, prior stroke 9,5%, chronic renal failure 40,5%, obstructive pulmonary disease 21,4% of the patients. Mean Logistic EuroScoreI/II: 16,68/10,73% (expected mortality). Results and Conclusions: Excellent results were achieved in patients undergoing aortic valve replacement with Perceval S sutureless bioprostheses and concomitant coronary artery bypass grafting. Although high aortotomy is needed for Perceval S implantation, is possible to perform proximal anastomosis for saphenous grafts properly. Perceval S is a feasible alternative for patients with aortic valve stenosis and coronary artery disease, with shorter cross-clamp and extracorporeal circulation times and low rate of complications.

A Model of Anterograde Oxygenated Lung Blood Flow in Acardia.

In extreme situations such as hyperacute rejection of heart transplant or major heart trauma, heart explantation and extracorporeal membrane oxygenation (ECMO) hemodynamic support might be the only means for survival. In our previous model of acardia, pulmonary artery (PA) was clamped and did not receive any anterograde blood flow. A model of anterograde PA perfusion might be necessary to avoid ischemic pulmonary damage in prolonged ECMO in acardia. The aim of this study was to describe the surgical technique and to determine the feasibility of an anterograde lung perfusion in acardia through the anastomosis of the right internal mammary artery (RIMA) to the PA. A venoarterial cardiopulmonary bypass was established in three pigs (72 ± 2.6 kg) by the transjugular insertion to the caval axis of a double-staged cannula with carotid artery return. Heart was excised and ECMO was established as previously reported. Right internal mammary artery was harvested and after measurement of its output (93.3 ± 5.8 ml/min, representing 2.17% ± 0.15% of total pump flow), it was anastomosed to PA. Right internal mammary artery anastomosis to PA is a feasible, safe, and easy to perform maneuver assuring an anterograde lung perfusion in acardia.

Perceval S and Coronary Artery Bypass Grafting, Contradiction or Full Harmony?

Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, female 35,7%. Cardiovascular risk factors: Hypertension 97,6%; Diabetes 38,1%, Dyslipidemia 69%, peripheral vascular disease 38,2%, prior stroke 9,5%, chronic renal failure 40,5%, obstructive pulmonary disease 21,4% of the patients. Mean Logistic EuroScoreI/II: 16,68/10,73% (expected mortality). Results and Conclusions: Excellent results were achieved in patients undergoing aortic valve replacement with Perceval S sutureless bioprostheses and concomitant coronary artery bypass grafting. Although high aortotomy is needed for Perceval S implantation, is possible to perform proximal anastomosis for saphenous grafts properly. Perceval S is a feasible alternative for patients with aortic valve stenosis and coronary artery disease, with shorter cross-clamp and extracorporeal circulation times and low rate of complications.

Czynniki ryzyka zwiększonego drenażu klatki piersiowej u pacjentów poddawanych operacji pomostowania aortalno-wieńcowego bez użycia krążenia pozaustrojowego

Introduction. The aim of the study is to identify risk factors of increased postoperative bleeding after off-pump surgical treatment of coronary artery disease (OPCAB). Material and methods. A retrospective study including all patients undergoing OPCAB (2004–2008) at a single-center institution, who were analyzed with statistical methods to find risk factors increasing postoperative bleeding. Statistical significance was determined at the level of p < 0.05. Results. One thousand two hundred and fifty-three patients aged 65.5 ± 9.6 were enrolled into the study. The average amount of drained blood on the first day after the surgery was 716.74 ± 430.12 mL. Seventy-six patients (6%) underwent surgical re-exploration due to postoperative bleeding. Factors elevating mediastinal drainage on the first day after the surgery included: advanced coronary artery disease, administration of clopidogrel at least 5 days before surgery and arterial grafts. Patients also had a higher mediastinal drainage when grafted: left internal mammary artery (LIMA), LIMA and right internal mammary artery (RIMA) as well as LIMA and left radial artery (LRA) (p < 0.001). Factors elevating mediastinal drainage were: lower body mass index (BMI) (according to World Health Organization groups) of operated patients (p = 0.023), even lower value of the additive EuroScore (p < 0.001) and logistical EuroScore (p = 0.001), longer duration of operations (p < 0.001) and increasing number of grafts (p < 0.001). When analyzed according to deciles of BMI and body surface area, the higher drainage was found, the higher decile of BMI was noted (p < 0.0001), but the lower drainage was found, the higher decile of BSA was noted (p < 0.0001). Finally, no differences were found between deciles 2 and 3, 3 and 4, 4 and 5, 5 and 6, 6 and 7 and the results were similar to non-indexed values (p < 0.001). The overall regression model showed that patients who had greater amounts of blood drained had: lower value of BMI (p < 0.001), received clopidogrel more often (p < 0.001), grafted bilateral internal mammary arteries (BIMA) (p < 0.001) and longer lasting operation (p < 0.001). Conclusions. Our results suggest that overweight and obese patients have a significantly lower risk of elevated blood drainage. Lost blood should be probably considered an indexed parameter, however our observation needs further evaluation. Surgeons should pay special attention to patients with diabetes, patients with multivessel disease and those who had BIMA used as grafts.

Abstract 12912: Impact of Graft Configuration of The Right Internal Mammary Artery in Coronary Artery Bypass Grafting: In-situ Versus Y Composite versus Aorto-coronary Bypass

Background: Right internal mammary artery (RIMA) has been used as second graft with various configurations. The aim of this study was to compare the patency of RIMA with using either aorto-coronary bypass (AC) or Y composite grafting proximally anastomosing to left internal mammary artery (LIMA) or in-situ grafting. Methods: Between January 1996 and June 2013, 324 patients underwent isolated coronary artery bypass grafting (CABG) using RIMA in addition to LIMA-left anterior descending artery (LAD) bypass. Target vessel of RIMA was either diagonal or circumflex branch with significant stenosis. Those patients were divided into 3 groups according to the proximal anastomosis site of RIMA. Group I contained 247 cases with in-situ RIMA grafting. Group A contained 33 cases with AC bypass with proximal anastomosis of RIMA to ascending aorta. Group Y contained 43 cases with Y composite grafting with proximal anastomosis to LIMA. Patients were evaluated by coronary angiography or CT scan postoperatively at discharge and during follow up. Graft patency and risk factors influencing IMA patency were statistically investigated. Results: RIMA patency at discharge were 97.6% in group I and 97.0% in group A, 93.0% in group Y, respectively (p=0.695). RIMA patency in 5 years were 90.5% in Group I, 100% in group A, 88.4% in group Y, respectively (Logrank P=0.309). LIMA patency at discharge were 99.2% in group I and 97.0% in group A, 97.7% in group Y, respectively (p=0.438). LIMA patency in 5 years were 100% in group A, 96.0% in group I, 76.2% in group Y (Logrank P= 0.009). Survival rate in 5 years were 89.7% in group I, 86.6% in group A, 60.7% in group Y (Logrank P= 0.011). Multivariate analysis showed Y composite grafting as risk factor in late LIMA occlusion (p=0.024, Hazard ratio (HR) 6.867, 95% Confidence Interval (CI) 1.29-36.5) and late death (p&lt;0.001 HR 2.99, 95% CI 1.70-5.27). Conclusion: In our study, the patency of RIMA was not significantly different between the groups, but LIMA patency was inferior when used as the inflow of Y composite grafting with RIMA. Y composite grafting may impact on the patency of LIMA and furthermore late survival.

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: A case-control study of 1526 patients

Objective: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG. Methods: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001–2013) was conducted to investigate the impact of the two strategies on early and late outcomes. Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2–3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0–2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1–9.7) and obese patients (HR 2.1; 95% CI 0.8–5.46). Conclusions: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

Searching for the second best graft for coronary artery bypass surgery: a network meta-analysis of randomized controlled trials

There is a lack of unequivocal evidence basis for selecting the best second conduit in coronary artery bypass grafting (CABG). We thus aimed to perform head-to-head relative effect estimate on angiographic outcomes for second conduits, including the right internal mammary artery (RIMA), radial artery (RA), right gastroepiploic artery (RGEA) and saphenous vein graft (SVG) by means of network meta-analysis of randomized controlled trials (RCTs). Databases were searched for RCTs comparing angiographic outcomes (≥4 weeks) of second conduits in CABG. Odds ratios (95% confidence intervals) were computed with Markov Chain Monte Carlo simulation. A total of nine RCTs were identified, including 2780 patients and 1620 angiographic results available for analysis to compare RIMA (n=145) versus RA (n=871) versus RGEA (n=92) versus SVG (n=845). The mean time to angiographic follow-up ranged from 1 to 7.7 years. An SVG was significantly associated with a 4-fold (1.67-16.00) and 3-fold (0.78-22.20) increased risk of late (≥4 years) functional graft occlusion when compared with the RIMA and RA, respectively. A RIMA was associated with a non-significant 27% absolute risk reduction for functional graft occlusion when compared with the RA. The present network meta-analysis consistently demonstrated an angiographic superiority of RIMA and RA over SVG. The RIMA is expected to achieve a better patency rate than the RA, but further studies are needed.

Should dialysis-dependent patients with upper limb arterio-venous fistulae undergoing coronary artery bypass grafting avoid having ipsilateralin situmammary artery grafts?: Table 1:

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether dialysis-dependent patients with upper limb arterio-venous fistulae (AVFs) undergoing coronary artery bypass grafting should avoid having ipsilateral in situ internal mammary artery (IMA) grafts. A literature search performed yielded 28 peer reviewed articles, of which 21 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The papers identified included 478 patients, of whom 219 had in situ IMA grafts with ipsilateral upper limb arterio-venous fistulae. There was a substantial variation between the papers, from single case reports to small retrospective cohort studies, but no randomized, controlled trials. The largest retrospective study included 155 patients and followed up for up to 5 years. Methods used to determine coronary steal included clinical assessment, electrocardiogram or echocardiographic changes, Doppler ultrasound of mammary arteries and angiography. The aggregate evidence suggested that 61 of the 219 patients with ipsilateral IMA grafts developed some clinical or physiological evidence of malperfusion during the use of the AVFs for dialysis. Comparisons with the contralateral IMA suggested that 27 of the 61 patients suffered similar problems when dialysis was applied. A number of studies used controls, including in situ right internal mammary artery (RIMA) flow and patients not on dialysis. In total, 32 patients had their in situ RIMA flow measurements studied, of which none showed any statistically significant flow alteration. While further strong evidence to demonstrate long-term outcomes is required, we recommend the avoidance, where possible, of ipsilateral in situ IMA grafts in patients with an upper limb AVF. There is sufficient experimental and anecdotal evidence to suggest that steal occurs and that in some patients, this has clinical implications on both morbidity and mortality. In this scenario, the use of the contralateral mammary is strongly advocated to maximize the patency of grafts in an already high-risk population.

Does grafting of left anterior descending artery with right internal mammary artery have an impact on late outcomes in the context of multiple arterial grafting?

Background Universally, anastomosis of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is accepted as the gold standard in coronary artery bypass grafting. The use of the right internal mammary artery (RIMA) for grafting the LAD has recently emerged as an alternative to avoid composite configuration in multiple arterial grafting using bilateral internal mammary arteries. Whether this recently emerged alternative strategy of RIMA to LAD is as effective as the well-established gold standard LIMA to LAD remains unknown. We investigated the impact of using RIMA for grafting of LAD on late outcomes in the context of multiple arterial grafting.

症例 左右冠動脈および右内胸動脈より肺動脈狭窄,閉塞部に特異な側副血行路を認めた大動脈炎症候群の1症例

症例 左右冠動脈および右内胸動脈より肺動脈狭窄,閉塞部に特異な側副血行路を認めた大動脈炎症候群の1症例

Reply to Saha

I want to thank Dr Saha for his kind remarks regarding our recent study [1, 2]. His observations are relevant, since there are varying philosophies regarding the configuration of the internal mammary arteries (IMAs) in coronary artery bypass graft surgery (CABG). Our study represents the experience of four different surgeons over 17 years (1994–10). In response to whether the IMAs were used ‘in situ’ or as a ‘Y’-graft, practitioners favoured different IMA configurations. Generally, the right IMA (RIMA) was used as an ‘in situ’ conduit when grafting the ramus intermedius or a very proximal obtuse marginal branch. When grafts were necessary in more distant territories off the left circumflex artery, the RIMA was either anastomosed to the ascending aorta (AA) or to the hood of a vein graft on the AA when the IMA was of small caliber. The majority of RIMAs were used to graft the circumflex territory. The ‘Y’-configuration represented a minority of cases in our series. In Table 5 of our study, the stroke rate for the off-pump left IMA (LIMA)-saphenous vein graft and bilateral IMA (BIMA) groups was 0%. We use a true no-touch technique of the aorta when the AA appears to harbour significant atherosclerotic disease by transesophageal echocardiography (TEE). Intraoperative TEE was in routine use at the beginning of our study. When significant disease was found on the AA, the RIMA was either anastomosed to the LIMA in a ‘Y’-type construct or anastomosed to the AA using a nonclamping occluder type of device. Propensity matching was performed using the pre-operative characteristics of both groups; no pre-screening for stroke was undertaken in the construction of the different cohorts. Several techniques can be used to avoid stroke, but none of them appears to be infallible [3]. As we all know, stroke is multifactorial and can rarely be attributable to one aetiology. The most successful approach appears to be careful preoperative screening of CABG patients, so that all the different sources of embolic disease can be evaluated and different intraoperative strategies can be utilized to prevent them. I read the technique described by Dr Saha et al. [4] of their in situ IMA graft construct, and it appears to be easy to implement. Nevertheless, a technique should be tailored to the surgeon performing the procedure, so he/she feels comfortable with it. I am not sure any particular strategy has been conclusively proven to be superior to another, as it is related to the experience the group has developed in that particular approach. Finally, I agree with Dr Taggart [5] that there exists robust published data debunking the old theory that the use of BIMA carries a higher rate of early mortality and/or significant morbidity. Obviously, clinical judgment must be exercised when deciding to use these conduits, particularly in such patients like the morbidly obese and poorly controlled diabetics. However, this cannot justify the low use of BIMA in USA (4%) and Europe (10%) [6]. The LIMA use became the standard of care through three decades of evidence-based research. I believe that we have reached a point where BIMA use should become a quality metric to assess the performances of different surgical units undertaking CABG.

Anomalous right coronary artery from the left sinus: a minimally invasive approach

Anomalous right coronary artery arising from the left sinus (ARCA) is a known cause of sudden cardiac death, particularly in young athletes. Surgery is recommended for all adult patients who are symptomatic or who have evidence of exercise-induced myocardial ischemia. Surgical options include coronary artery bypass grafting (CABG) and anatomic correction by unroofing the ostium or by reimplanting the ostium into the right sinus of Valsalva. We describe the rationale and technique of a minimally invasive right thoracotomy approach for correction of ARCA. We reviewed all patients with coronary artery disease operated upon at Mount Sinai Medical Center. Between March 2008 and September 2010, 17 patients underwent surgery for anomalous coronary origin from the opposite sinus of Valsalva. Nine of these patients had ARCA. We describe four adult patients with ARCA who were operated upon using a small right anterior thoracotomy incision to perform a right internal mammary artery (RIMA) to right coronary artery (RCA) bypass with ligation of the proximal RCA. This was performed under direct vision and without cardiopulmonary bypass. There were two male and two female patients. Mean age was 55.3 ± 4.8 years (range 50-61 years). Three of the patients manifested chest pain and one each syncope, dyspnea, and palpitations. Two patients had preoperative stress testing that was positive for ischemia. Postoperative follow-up (mean 14 months and range 5-37 months) is complete. All patients are alive and asymptomatic. ARCA can be managed with good early and midterm results using a minimally invasive right thoracotomy approach.

Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multivessel disease?

Diabetic patients often present with diffuse coronary disease than nondiabetic patients posing a greater surgical challenge during off-pump revascularization. In this study, the safety, feasibility, and completeness of revascularization for this subset of patients was assessed. From 2002 to 2008, 1015 diabetic patients underwent myocardial revascularization. Patients received either off-pump coronary artery bypass (OPCAB; n = 540; 53%) or coronary artery bypass grafting (CABG; n = 475; 47%). Data collection was performed prospectively and data analysis was done by propensity-score (PS)-adjusted regression analysis. Primary endpoints were mortality, major adverse cardiac and cerebrovascular events (MACCEs), and a composite endpoint including major noncardiac adverse events (MNCAEs) such as respiratory failure, renal failure, and rethoracotomy for bleeding was applied. An index of complete revascularization (ICOR) was defined to assess complete revascularization by dividing the total number of distal anastomoses by the number of diseased vessels. Complete revascularization was assumed when ICOR was >1. OPCAB patients had a significantly lower mortality-rate (1.1% vs 3.8%; propensity-adjusted odds ratio (PAOR) = 0.11; p = 0.018) and displayed less frequent MACCE (8.3% vs 17.9%; PAOR = 0.66; p = 0.07) including myocardial infarction (1.3% vs 3.2%; PAOR = 0.33; p = 0.06) and stroke (0.7% vs 2.3%; PAOR = 0.28; p = 0.13). Similarly, a significantly lower occurrence of the noncardiac composite endpoint (MNCAE) (PAOR = 0.46; confidence interval (CI) 95% 0.35-0.91; p < 0.001) was detected. In particular, lesser respiratory failure (0.9% vs 4.3%; PAOR = 0.24; p = 0.63) and pleural effusions (3.3% vs 7.5%; PAOR = 0.45; p = 0.04) occurred, so that fast extubation (≤ 12 h postoperative) was more frequently possible (58.3% vs 34.2%; PAOR = 1.64; p = 0.007). The number of arterial grafts was significantly higher among OPCAB patients (1.54 ± 0.89 vs 1.33 ± 0.81; p = 0.006) due to a more frequent use of the right-internal mammary artery (35.6% vs 22.9%; p < 0.001). ICOR was significantly higher among CABG patients (1.24 ± 0.34 vs 1.30 ± 0.28; p = 0.001). However, for similar proportions in both groups, an ICOR > 1 was achieved clearly indicating complete revascularization (94.3% vs 93.7%; p = 0.24). OPCAB offers a lower mortality and superior postoperative outcomes in diabetic patients with multivessel disease. Arterial grafts are used more frequently that may contribute to better long-term outcomes and the OPCAB approach does not come at the cost of less complete revascularization.

Off-pump Y-graft coronary artery bypass in a patient with situs inversus totalis

Situs inversus is the mirror image of situs solitus. Situs inversus with dextrocardia is termed 'situs inversus totalis'. Since situs inversus totalis is a rare condition, there are a only a few reports about off-pump coronary artery bypass (OPCAB) in these patients. A 67-year-old man with a diagnosis of situs inversus totalis and three-vessel disease, underwent an elective surgical revascularization. The operation consisted of an OPCAB using a total arterial composite Y-graft. The right internal mammary artery (RIMA) and the left radial artery (RA) were harvested as pedicles and they were anastomized as Y-grafts. Three distal anastomoses were performed: the RIMA to the anterior descending artery and the RA sequentially to the obtuse marginal branch and the posterior descending artery. The peculiarity of OPCAB no-touch with a composite graft in a patient with situs inversus totalis consisted in the mirroring of the whole surgical set-up and of the surgical strategy. The surgery as well as the postoperative period were uneventful. This case report shows the feasibility of OPCAB 'no-touch' with composite arterial grafting in a patient with situs inversus totalis.

Recovery of distal coronary flow reserve in LAD and LCx after Y-Graft intervention assessed by transthoracic echocardiography

BackgroundY- graft (Y-G) is a graft formed by the Left Internal Mammary Artery (LIMA) connected to the Left Anterior Descending Artery (LAD) and by a free Right Internal Mammary Artery (RIMA) connected to LIMA and to a Marginal artery of Left Circumflex Artery (LCx). Aim of the work was to study the flow of this graft during a six months follow-up to assess whether the graft was able to meet the request of all the left coronary circulation, and to assess whether it could be done by evaluation of coronary flow reserve (CFR).MethodsIn 13 consecutive patients submitted to Y-G (13 men), CFR was measured in distal LAD and in distal LCx from 1 week after , every two months, up to six months after operation (a total of 8 tests for each patient) by means of transthoracic echocardiography (TTE) and Adenosine infusion (140 mcg/kg/min for 3-6 min). A Sequoia 256, Acuson-Siemens, was used. Contrast was used when necessary (Levovist 300 mg/ml solution at a rate of 0,5-1 ml/min). Max coronary flow diastolic velocity post-/pre-test ≥2 was considered normal CFR.ResultsCoronary arteriography revealed patency of both branches of Y-G after six months. Accuracy of TTE was 100% for LAD and 85% for LCx. Feasibility was 100% for LAD and 85% for LCx. CFR improved from baseline in LAD (2.21 ± 0.5 to 2.6 ± 0.5, p = 0.03) and in LCx (1.7 ± 1 to 2.12 ± 1, p = 0.05). CFR was under normal at baseline in 30% of patients vs 8% after six months in LAD (p = 0.027), and in 69% of patients vs 30% after six months in LCx (p = 0.066).ConclusionCFR in Y-G is sometimes reduced in both left territories postoperatively but it improves at six months follow-up. A follow-up can be done non-invasively by TTE and CFR evaluation.

A xiphoid approach for minimally invasive coronary artery bypass surgery.

The premise for adopting minimally invasive cardiac surgery techniques for myocardial revascularization is to reduce the patient's morbidity without compromising the efficacy of conventional coronary artery bypass. However, opening the pleura has been a limitation of using these approaches. We used the xiphoid approach as an alternative to opening the pleura and to minimize pain after minimally invasive coronary artery bypass surgery. We review our surgical experience in 55 patients who underwent minimally invasive direct coronary artery bypass (MIDCAB) surgery through a xiphoid approach between October 1997 and August 1999. Thoracoscopy (n = 31) or direct vision (n = 24) were used for internal mammary artery (IMA) harvesting. Mean patient age was 67 +/- 10 years and 65% were men. The mean Parsonnet score was 23 +/- 10. Performed anastomoses included left IMA (LIMA) to the left anterior descending (LAD) artery (n = 53), LIMA-to-LAD and saphenous vein graft from the LIMA to the right coronary artery (n = 1), and LIMA-to-LAD and right IMA (RIMA) to right coronary artery (n = 1). Postoperative complications included atrial fibrillation (12%), acute noninfectious pericarditis (12%), and acute renal failure (5%). Mean postoperative length of stay was 4 +/- 2 days. Angiography was performed in 16 patients and demonstrated excellent patency of the anastomoses. There was no operative mortality. Actuarial survival was 98% in a mean follow-up period of 11 +/- 5 months. Minimally invasive coronary artery bypass can be performed safely through a xiphoid approach with low morbidity, mortality, and a relatively short hospital stay.