Do beating heart techniques applied to combined valve and graft operations reduce myocardial damage?

We examined the outcomes of combined beating heart CABG and valve surgery (hybrid) and compared these to conventional CABG and valve surgery (conventional). Between April 1997 and March 2006, 388 patients received combined CABG and valve surgery. Patient characteristics and cardiac enzyme release were collected prospectively. To account for differences in case-mix we used logistic regression to develop a propensity score for hybrid group membership and then performed a propensity-matched analysis. One hundred and forty patients underwent hybrid operation with a mean logistic EuroSCORE of 13.5%, compared to 248 who underwent conventional operation with a mean logistic EuroSCORE of 10.9% (P=0.006). Eighty-two patients from each group were successfully matched. The mean logistic EuroSCORE after matching was similar between the groups (11.3% vs. 12.9%; P=0.48). The median number of grafts per patient was also similar, three in each group (P=0.98). Post-op CK-MB levels were found to be significantly lower for hybrid patients (44 U/I vs. 29.5 U/I; P=0.037). In-hospital mortality was not statistically different (9.8% vs. 6.1%; P=0.39). Survival at 5 years was 74% for hybrid and 71% for conventional group (P=0.92). CK-MB levels in patients receiving hybrid CABG and valve surgery are reduced compared to conventional CABG and valve surgery.     

Is 100% beating heart coronary by-pass justified?

Coronary by-pass on a beating heart may provide a safer form of surgical revascularization by avoiding the well-documented side effects of cardiopulmonary by-pass. In addition, off-pump bypass is suggested to be a good alternative to on-pump especially in high risk patients. This study reviews the feasibility of coronary by-pass on the beating heart in all patients referred to surgery. Two hundred and ninety-four patients operated on the beating heart were prospectively followed and compared to the control group of 100 consecutive patients operated with the conventional method. There were no significant differences between the groups with respect to risk factors, except the incidence of chronic obstructive pulmonary disease and ejection fraction which were higher in the conventional group, whereas peripheral vascular disease was higher in the beating heart group. There was more distal anastomosis in the conventional group. Postoperative inotrope requirement, peak creatine phosphokinase- MB, ventilation time, blood loss in the first 24 h, transfusion needs, new atrial fibrillation and length of hospital stay were significantly lower in the beating heart operations. However, there were no significant differences between the groups in terms of neurological complications, chest infection, intraaortic balloon pump usage and mortality. In conclusion, multivessel off pump coronary by-pass is feasible with the same or better results as it is observed in the conventional technique when postoperative bleeding, neurogenic complications, arrythmias, hospital stay, overall morbidity and mortality are compared.     

Clamshell or sternotomy for double lung or heart-lung transplantation?

OBJECTIVE: To evaluate the influence of either incision on the lungs and chest wall. METHODS: Ninety-two double lung (DLT) or heart-lung (HLT) transplantations were done since January 1990. There were 22 (24%) hospital deaths, leaving 70 patients with complete data for evaluation. We did 38 DLT and 32 HLT for end-stage chronic respiratory failure (n = 22) and primary (n = 34) or secondary (n = 14) pulmonary hypertension, using 37 fourth or fifth interspace clamshell incisions and 33 median sternotomies. RESULTS: The clamshell group included a higher percentage of DLTs (73 vs. 33%, P = 0.001) but recipient age, gender, preoperative diagnosis, bronchial anastomotic complications, number of cytomegalovirus infection, episode of acute rejection per patient-months and incidence of bronchiolitis obliterans were not statistically different between the two groups. At a follow-up time of 3.7 +/- 2 years, the overall 5-year survival of 57% was not influenced by the type of incision. The clamshell incision caused sternal over-riding in 12 (32%) patients, and eight surgical clamshell revision were necessary as compared with one median sternotomy (P = 0.02). The clamshell incision was associated with a significantly higher incidence of postoperative chronic pain (27 vs. 6%, P = 0.02). Postoperative mechanical properties of the chest wall were significantly (P < 0.0001) worse in the clamshell-group patients while the intrinsic properties of the airways were not different. CONCLUSIONS: The clamshell incision results in more postoperative deformity, chronic pain, and impaired function as compared with median sternotomy. A bilateral anterolateral thoracotomy without division of the sternum is proposed for the sequential bilateral lung transplantation technique.     

Surgical revascularization in patients with poor left ventricular function: on- or off-pump?

BACKGROUND: Patients with left ventricular dysfunction and low ejection fraction (EF) are at high-risk of complication and mortality after coronary artery bypass grafting (CABG). The potential success of off-pump CABG in this high-risk population has yet to be determined. The purpose of this study is to compare the outcome of off-pump coronary artery bypass (OPCAB) and conventional coronary artery bypass (CCAB) in patients with poor left ventricular function, all from a single institution. METHODS: Data on patient demographics, preoperative risk factors, operative and postoperative outcomes were collected retrospectively on all patients having undergone isolated CABG between January 1, 1998, and October 31, 2001. RESULTS: A total of 77 patients (31 OPCAB/46 CCAB) were identified as having an ejection fraction (EF) of < or = 0.35. Of these, 52 had EF < or = 0.30 (21 OPCAB/31 CCAB) and 31 patients had EF < or = 0.25 (10 OPCAB/21 CCAB). Operative mortality was 3.2% after the OPCAB procedure versus 10.9% for the CCAB (p = 0.39). Use of intraaortic balloon pump (6.5%) was rarely required. The OPCAB procedure resulted in significantly less requirement for blood transfusions (p < 0.05), fewer distal anastomoses per patient (p < 0.01), and a higher incidence of atrial fibrillation (p < 0.05) compared with CCAB. CONCLUSIONS: Patients with poor left ventricular function may undergo surgical revascularization using off-pump technique with relatively good results and low mortality levels. The lower number of grafts performed on the off-pump procedure did not seem to affect clinical outcomes.     

Is hybrid coronary revascularization favored by cardiologists or cardiac surgeons?

We investigated the present use of integrated coronary revascularization (ICR) by interviewing a sample of United States invasive cardiologists and cardiac surgeons. Both groups still favor left internal mammary artery (LIMA) grafting to revascularize the left anterior descending (LAD) coronary artery. There remains a lack of exposure to and acceptance of ICR, especially for surgeons. We report the findings of this national survey of 180 cardiologists and 160 surgeons, as they may serve as an indicator of the current opinions about ICR and its future applicability as a standard method of coronary artery revascularization. We discuss the limited popularity of minimally invasive hybrid procedures and the importance of further exposing cardiologists and surgeons to ICR.     

Pure single-port laparoscopic surgery or mix of techniques?

Purpose

Laparoendoscopic single-site surgery (LESS) has emerged in the recent years as an alternative approach to conventional laparoscopic surgery which is accompanied by additional advantages over laparoscopy. In this work we attempt to review the current literature and to investigate the possible combination of LESS to other currently available approaches such as natural orifice transluminal endoscopic surgery (NOTES), needlescopic and robotic laparoscopic surgery.

Methods

Extensive literature search on the topics of LESS, hybrid and pure NOTES, Needlescopic-assisted LESS and “Robot-assisted LESS” took place. Additionally, the accumulated experience from 118 LESSs performed in our departments is presented in an attempt to provide evidence regarding the mix of technique in LESS in urology.

Results

The challenging nature of LESS limits the broader application and acceptance. Expanding experience in single-site surgery has currently provided tools such as transvaginal access, needlescopic instruments and robot assistance that can aid LESS and enhance its efficiency without compromising any of its advantages. A mix of these techniques with LESS could ease the stiff learning curve of the second and benefit not only its performance but also the adaptation of LESS as a standard practice.

Conclusion

Pure LESS although feasible, remains a technical challenge for the surgeon, preventing the widespread application of the technique. The goal of urologists on LESS surgery should not be the purity of LESS approach, but the superiority against already established techniques. A mix of techniques could be a key for the documentation of the advantages of LESS over conventional laparoscopy.     

Is early tracheostomy safe in cardiac patients with median sternotomy incisions?

BACKGROUND: Tracheostomy after cardiac operation through a median sternotomy is believed to increase the risk of mediastinitis, leading to debate as to whether early tracheostomy is safe in these patients. METHODS: A record search of patients undergoing cardiac operation through median sternotomy was done. Day and duration of tracheostomy were correlated to day of positive bacteriological evidence and clinical outcome for the patient. The method of tracheostomy was also recorded. RESULTS: Of 174 cases, 4 patients had mediastinitis, 3 before tracheostomy was performed. Of these three patients, 2 survived and the third died of multiorgan failure 46 days after the procedure. The fourth patient, on immunosuppressive therapy for severe rheumatoid arthritis and pulmonary fibrosis, had tracheostomy performed at primary operation, developed fatal mediastinitis after 6 days, and died 18 days postoperatively of multiorgan failure. Of the tracheostomies performed, 24 (14%) were percutaneous, and 110 (63%) were achieved using standard surgical techniques (in 40 cases type was unrecorded). In 72 cases (41%), tracheostomy was performed on or before day 7, 11 (6%) being performed before 48 hours. Mortality occurred in 38 (22%). CONCLUSIONS: There is no demonstrable relationship between early tracheostomy and mediastinitis in median sternotomy patients.     

Is lower extremity revascularization worthwhile in patients with end-stage renal disease?

BACKGROUND: The purpose of this study was to review the results of lower extremity revascularization in patients with end-stage renal disease and to determine in these patients the functional benefit and cost of an aggressive approach to limb preservation. METHODS: During a 5-year period at our institution, 33 bypass operations were performed on 31 limbs of 23 dialysis-dependent patients. Indications for revascularization were limited (18) or extensive (12) tissue loss or ischemia without tissue loss (3). Procedures included aortobifemoral bypass (1), femoropopliteal bypass (10), and femorotibial/pedal bypass (22). A digital or transmetatarsal amputation was performed in 57% of limbs. RESULTS: The 30-day primary patency was 100%. Cumulative primary and secondary patency rates at 2 years were 65% and 79%, respectively. Limb salvage was 67% and 59% at 1 and 2 years, respectively. Patient survival was poor (47% at 2 years). Peritoneal dialysis was predictive of poor survival (P <.001). Four of 5 patients on peritoneal dialysis died within 3 months of intervention. Extensive tissue loss was predictive of a diminished rate of limb salvage (P =.027). Only 39% of limbs with extensive tissue loss were salvaged at 1 year compared with 78% and 100% of limbs with limited and no tissue loss, respectively. The average hospital cost was $44,308 per year of limb salvage. CONCLUSIONS: Although revascularization of ischemic limbs in dialysis patients can be achieved with an excellent initial graft patency and reasonable limb salvage, patient survival is poor and costs are high. A selective approach to revascularization in these complicated patients may be indicated. For patients treated with peritoneal dialysis and for those with extensive tissue loss, primary amputation may be the preferred approach.