Characteristics of Patients with Patent versus Closed Left Internal Thoracic Artery Grafts before Redo Revascularization

Summary BACKGROUND: The aim of this study was to examine the impact of internal thoracic artery (ITA) graft patency on clinical course between initial and redo coronary artery bypass grafting (CABG). METHODS: 82 patients out of 553 redo CABG between 1990 and 1999 underwent ITA grafting to the left anterior descending artery (LAD) and vein grafting to other vessels at initial revascularization. At reoperation 54 patients (group I) showed a patent ITA, while 28 patients (group II) showed ITA occlusion. All patients underwent coronary angiography prior to initial and redo CABG. RESULTS: Absence of angina after initial CABG and time to redo operation was longer in group I (I vs. II: 5.1 ± 3.3 vs. 3.4 ± 3.6 years, p = 0.01; 6.0 ± 3.2 vs. 3.9 ± 3.6 years, p = 0.03; respectively). The incidence of myocardial infarction (MI) in the lateral/posterior myocardium was higher in group I (I vs. II: 38.9 % vs. 14.3 %; p = 0.021). MI rate of the anterior wall was comparable between both groups. Rate of interventional revascularization between operation was significantly lower in group I (I vs. I: 11.1 % vs. 32.1 %; p = 0.019). The rate of stenoses in the circumflex coronary artery (RCX) and the right coronary artery (RCA) increased significantly in group I compared to group II (p = 0.002 for RCX of 80–95 %; p = 0.034 for RCX > 95 %; p = 0.047 for RCA > 95 %). The number of occluded vein grafts to RCX and RCA was higher in group I (I vs. II: 48 % vs. 22 %, p = 0.028; 50 % vs. 17 %, p = 0.023; respectively). CONCLUSIONS: The angina-free interval after initial CABG between operations is longer in patients with patent ITA. However, the increase of lesions number in native vessels as well as in vein grafts is significantly higher in RCX and RCA systems in such patients due to a longer period between operations compared to patients with closed ITA. Hence, the risk for MI in the lateral/posterior myocardium in RCX/RCA territories is higher, which remains undetected in many cases because of sufficient perfusion of the anterior wall by patent ITA.

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Charakteristik von Patienten mit offenen versus verschlossenen Brustwandarterien-Grafts vor Re-Myokardrevaskularisation

Zusammenfassung GRUNDLAGEN: Ziel dieser Studie war es, den klinischen Verlauf zwischen operativer Erst- und Re-Myokardrevaskularisation bei Patienten mit offenen Arteria-thoracica-interna-Grafts (ITA) auf den Ramus interventrikularis anterior (RIVA) im Vergleich zu Patienten mit geschlossenen ITA-Grafts zu untersuchen. METHODIK: Untersucht wurden 82 Patienten vor dem Zweiteingriff von insgesamt 553 Patienten, die sich einer erneuten Myokardrevaskularisation unterzogen. Alle Studienpatienten erhielten bei der Erstoperation sowohl einen ITA-Graft auf den RIVA als auch venöse Grafts auf andere Zielgefäße. Vor der zweiten Operation zeigten 54 Patienten (Gruppe I) einen offenen ITA-Graft und 28 Patienten (Gruppe II) einen verschlossenen ITA-Graft. Bei allen Patienten wurde sowohl vor der ersten als auch vor der zweiten Operation eine Koronarangiographie durchgeführt. ERGEBNISSE: Das Angina-pectoris-freie Intervall sowie der Zeitraum bis zum zweiten Eingriff waren länger in Gruppe I (I vs. II: 5,1 ± 3,3 vs. 3,4 ± 3,6 Jahre, p = 0,001; 6,0 ± 3,2 vs. 3,9 ± 3,6 Jahre, p = 0,03). Die Myokardinfarktrate (MI) im postero-lateralen Bereich war höher in Gruppe I (I vs. II: 38,9 % vs. 14,3 %; p = 0,021). Die MI-Rate im anterioren Myokard war vergleichbar. Die Anzahl der perkutanen Revaskularisationen zwischen den Operationen war niedriger in Gruppe I (I vs. II: 11,1 % vs. 32,1 %; p = 0,019). Die Zunahme der Anzahl von Stenosen in Ramus circumflexus (RCX) und rechter Koronararterie (RCA) war signifikant höher in Gruppe I (p = 0,002 für RCX mit 80- bis 95%igen Stenosen; p = 0,034 für RCX mit > 95%igen Stenosen; p = 0,047 für RCA mit > 95%igen Stenosen). Die Anzahl der verschlossenen venösen Grafts zum RCX- und RCA-System war signifikant höher in Gruppe I (I vs. II: 48 % vs. 22 %, p = 0,028; bzw. 50 % vs. 17 %, p = 0,023). SCHLUSSFOLGERUNGEN: Das anginafreie Intervall zwischen den Operationen ist signifikant länger bei Patienten mit offenen ITA-Grafts. Bei diesem Patientenkollektiv ist infolge eines längeren Zeitintervalls zwischen den Operationen die Zunahme der Koronarstenosen der nativen Gefäße und venösen Grafts im RCX- und RCA-System im Vergleich zu Patienten mit verschlossenen ITA-Grafts signifikant höher. Daher ist das Myokardinfarktrisiko für diese Patienten signifikant erhöht, welches bei suffizienter Durchblutung des anterioren Myokards oft nicht rechtzeitig erkannt wird.

     

"H" Graft from the Right Internal Mammary Artery to the Left Anterior Descending Coronary Artery: An Alternative Strategy in Reoperative Grafting of the LAD Territory

Reoperative grafting of the left anterior descending (LAD) coronary artery or its diagonal branches can be accomplished through a left anterior small thoracotomy (LAST) on the beating heart using the left internal mammary artery (LIMA) as a conduit. Patients in whom the LIMA has been used previously, however, are generally excluded from this approach unless an alternative technique is utilized. We describe a new technique applicable to these patients that consists of grafting the LAD through a LAST approach and connecting the graft to the right internal mammary artery (RIMA).     

Internal Mammary–Anomalous Left Anterior Descending Coronary Artery Graft in 16-Month-Old Infant with Tetralogy of Fallot: 30-Month Follow-up

Congenital anomalies of the coronary arteries can occur in conjunction with tetralogy of Fallot. We describe a case of unsuspected anomalous origin of the left anterior descending coronary artery arising from the right coronary artery that was discovered at the time of operation in a 16-month-old infant with tetralogy of Fallot. Successful direct vascular repair of the intracardiac anomalies was performed, including left internal mammary–coronary artery anastomosis. The patient, whom we believe to be the youngest to undergo this technique, underwent cardiac catheterization 21 months after operation. The successful results were confirmed at that time.     

Late Revascularization of the Anterior Descending Coronary Artery in a Young Patient with Previous Myocardial Infarction Caused by Blunt Chest Trauma An Option for the Left Internal Thoracic Artery?

A myocardial infarction secondary to a left anterior descending coronary artery (LAD) injury in a 29-year-old male, following a motorcycle accident, is reported. The option for late myocardial revascularization with in situ LAD/left internal thoracic artery (LITA) anastomosis is emphasized as the particularity of this case report.     

Pediatric Liver Transplantation Using Reduced and Hyper‐Reduced Left Lateral Segment Grafts: A 10‐Year Single‐Center Experience

Few studies have examined the long‐term outcomes and prognostic factors associated with pediatric living living‐donor liver transplantation (LDLT) using reduced and hyper‐reduced left lateral segment grafts. We conducted a retrospective, single‐center assessment of the outcomes of this procedure, as well as clinical factors that influenced graft and patient survival. Between September 2000 and December 2009, 49 patients (median age: 7 months, weight: 5.45 kg) underwent LDLT using reduced (partial left lateral segment; n = 5, monosegment; n = 26), or hyper‐reduced (reduced monosegment grafts; n = 18) left lateral segment grafts. In all cases, the estimated graft‐to‐recipient body weight ratio of the left lateral segment was more than 4%, as assessed by preoperative computed tomography volumetry, and therefore further reduction was required. A hepatic artery thrombosis occurred in two patients (4.1%). Portal venous complications occurred in eight patients (16.3%). The overall patient survival rate at 1, 3 and 10 years after LDLT were 83.7%, 81.4% and 78.9%, respectively. Multivariate analysis revealed that recipient age of less than 2 months and warm ischemic time of more than 40 min affected patient survival. Pediatric LDLT using reduced and hyper‐reduced left lateral segment grafts appears to be a feasible option with acceptable graft survival and vascular complication rates.     

How to Do It: Repair of Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) with Coronary Button Transfer and Lecompte Maneuver

Abstract An alternative technique of coronary button transfer and Lecompte maneuver for anomalous left coronary artery (ALCAPA) arising from left lateral pulmonary sinus is described. This technique was used by us successfully in four patients aged 6 months to 3.5 years, weighing from 4.7 to 16 kg. The importance of trapdoor technique and Lecompte maneuver is discussed. (J Card Surg 2010;25:225‐227)     

Liver Transplantation with Grafts from Controlled Donors after Cardiac Death: A 20‐Year Follow‐up at a Single Center

The first liver transplantation (LTx) in Sweden was performed in 1984, but brain death as a legal death criterion was not accepted until 1988. Between November 1984 and May 1988, we performed 40 consecutive LTxs in 32 patients. Twenty‐four grafts were from donors after cardiac death (DCD) and 16 grafts from heart‐beating donors (HBD). Significantly, more hepatic artery thrombosis and biliary complications occurred in the DCD group (p < 0.01 and p < 0.05, respectively). Graft and patient survival did not differ between the groups. In the total group, there was a significant difference in graft survival between first‐time LTx grafts and grafts used for retransplantation. There was better graft survival in nonmalignant than malignant patients, although this did not reach statistical significance. Multivariate analysis revealed cold ischemia time and post‐LTx peak ALT to be independent predictive factors for graft survival in the DCD group. In the 11 livers surviving 20 years or more, follow‐up biopsies were performed 18–20 years post‐LTx (n = 10) and 6 years post‐LTx (n = 1). Signs of chronic rejection were seen in three cases, with no difference between DCD and HBD. Our analysis with a 20‐year follow‐up suggests that controlled DCD liver grafts might be a feasible option to increase the donor pool.     

‘No Touch’ Techniques for Porcelain Ascending Aorta: Comparison Between Cardiopulmonary Bypass with Femoral Artery Cannulation and Off‐Pump Myocardial Revascularization

Abstract Background: Detection of severe atherosclerotic ascending aorta during coronary artery bypass grafting requires alterations in the standard surgical technique to reduce the probability of stroke‐related atheroembolization. Off‐pump coronary artery bypass grafting (OPCAB) confers the benefits of avoiding aortic cannulation and clamping, and may therefore attenuate this risk. Methods: OPCAB (n # 41) was compared to cardiopulmonary bypass (CPB) using femoral arterial cannulation and hypothermic fibrillatory arrest (n = 15), in patients with porcelain ascending aorta undergoing myocardial revascularization. In both groups, a ‘no touchrsquo; technique was applied by avoiding aortic cannulation and clamping. Proximal anastomoses on the atherosclerotic aorta were avoided by arterial grafting, (in‐situ or T‐graft configurations) in all cases. Results: Operative mortality was comparable (2.4% and 6.6% in the OPCAB and CPB groups respectively, p # NS). The rate of adverse neurological events, (two strokes and one transient ischemic attack), was higher in the CPB group (p # 0.0164). Based on brain CT, the nature of the recorded stroke suggested retrograde emboli. Three year survival (Kaplan‐Meier) for the OPCAB and CPB groups was 86.7% and 81.3%, respectively (p = NS). Occurrence of late neurological adverse events during follow‐up (8–51 months) was similar. Conclusions: In patients with porcelain ascending aorta undergoing myocardial revascularization, neurological outcome of OPCAB patients is better than CPB using femoral artery cannulation.     

ERCP and Endoscopic Sphincterotomy (ES): A Safe and Definitive Management of Gallstone Pancreatitis with the Gallbladder Left In Situ

Background and Aims  

UK guidelines recommend that patients with gallstone pancreatitis have cholecystectomy within 2 weeks of their pancreatitis. A proportion of these are elderly with significant comorbidities rendering them high risk for general anaesthesia and surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) may offer a safe alternative to cholecystectomy as definitive treatment in these patients.