Concomitant off-pump myocardial revascularization and pheochromocytoma resection

Surgical management of patients with coexisting ischemic heart disease and pheochromocytoma remains challenging. We present one such case in which hybrid myocardial revascularization (angioplasty with stenting and off-pump coronary artery bypass grafting) and resection of pheochromocytoma were undertaken. Unusual features included simultaneous coronary artery surgery and tumor resection and, in particular, coronary artery surgery being performed without cardiopulmonary bypass.     

Multivessel off-pump revascularization in octogenarians: early and midterm outcomes

BACKGROUND: Octogenarians are increasingly being referred for coronary artery revascularization. However, the prevalence of comorbid events and the propensity for neurologic dysfunction place octogenarians at higher risk for cardiopulmonary bypass-induced morbidity and mortality. Therefore, octogenarian patients represent a particularly attractive target for application of off-pump coronary artery bypass grafting. METHODS: From January 1999 to August 2001, 113 octogenarians had off-pump coronary artery bypass grafting. Their data were prospectively entered into the cardiac surgery database and analyzed retrospectively. Follow-up information was obtained through telephone survey. RESULTS: The mean age of the patients was 83 +/- 2.5 years, and the mean number of grafts per patient was 3.3 +/- 1. The most prevalent postoperative complication was atrial fibrillation (43%). Postoperative neurologic complications were seen in 5 patients (4%). There was one postoperative death (30-day mortality rate, 0.9%). The mean follow-up was 13.2 +/- 7 months and was complete for 90% of the patients. At the time of telephone survey, 85 (87%) of 98 patients were free from angina, and 91 (88%) were free from cardiac-related readmission. There were three late deaths. The majority of octogenarians (66%) reported that in retrospect, they would have the operation again. CONCLUSIONS: Off-pump multivessel revascularization in octogenarians is associated with excellent early and intermediate outcomes and provides a satisfactory quality of life.     

Multivessel off-pump revascularization in patients with severe left ventricular dysfunction.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of multivessel beating heart revascularization in a high-risk group of patients with severe left ventricular dysfunction as well as to provide intermediate survival and quality of life data. METHODS: Our prospectively updated database was queried to extract all patients with left ventricular ejection fraction < or =30% who underwent beating heart revascularization. Standard demographics, clinical profiles and outcomes were collected. Outcomes were compared with Society of Thoracic Surgeons (STS) benchmarks for all coronary artery bypass grafting (CABG) patients. Telephone interviews were conducted and survival and quality of life data were tabulated. In addition, morbidity and mortality outcomes were compared with a concurrent cohort of patients with similarly impaired left ventricular function who underwent conventional coronary artery bypass. RESULTS: One hundred off-pump coronary artery bypass grafting patients were identified and follow-up was 93% complete in these patients. Mean age was 67+/-10.5 years and mean ejection fraction was 26+/-4%. Twenty-one percent were females. Balloon counterpulsation support was used liberally in the perioperative period. Patients received a mean of 3.5 grafts with 83% internal mammary artery use. Observed mortality was 3% with a predicted mortality of 5.3%. Observed to expected ratio was 0.56. Incidence of adverse events compared favorably with both that reported in the STS for all CABG patients regardless of left ventricular function, and also to a concurrent CABG cohort. One-year survival was 85%. Freedom from cardiac readmission was 88% and freedom from angina was 83%. No patient required repeat percutaneous or surgical intervention. CONCLUSIONS: We conclude that multivessel off-pump revascularization in patients with severe left ventricular dysfunction is a safe and effective alternative to conventional grafting. Long-term follow-up is mandatory to confirm these encouraging intermediate outcomes.     

Multivessel coronary revascularization with bilateral internal thoracic artery grafts

Sixteen patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts between 1988 and 1989 at the Okayama University Hospital. A total 39 coronary grafts were performed, being an average of 2.4 grafts per patient. Each patient received bilateral ITA grafts, and in 5 patients an additional 7 grafts were constructed with 5 autologous veins and 2 gastroepiloic arteries. The right ITA was grafted as a free graft in 4 patients. The ITA graft patency rate was 96.8 per cent (31/32) at the time of hospital discharge. The postoperative morbidity included one reoperation for bleeding and one myocardial infarction. Coronary artery bypass grafting with bilateral ITA grafts can be safely performed and its application facilitates complete revascularization with arterial grafts.     

Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting

BACKGROUND: Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization. METHODS: From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique. RESULTS: There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses). CONCLUSIONS: A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.     

Percutaneous ventricular assist device support during off-pump surgical coronary revascularization

Intraaortic balloon pump counterpulsation has been used for mechanical circulatory support in cardiogenic shock patients, but percutaneous left ventricular assist devices can provide superior circulatory support in the same group of patients. We describe the case of a patient in cardiogenic shock after a myocardial infarction. A percutaneous ventricular assist device was used to provide immediate active hemodynamic support, and, because the patient's condition necessitated surgical revascularization, percutaneous left ventricular assist device support was continued during off-pump coronary artery bypass.     

Coronary revascularization with or without cardiopulmonary bypass in patients with preoperative nondialysis-dependent renal insufficiency

Background. Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing conventional coronary artery bypass grafting. Off-pump coronary artery bypass operations have been shown to reduce renal dysfunction in patients with normal renal function, but the effect of this technique in patients with preoperative nondialysis-dependent renal insufficiency is unknown.

Methods. From June 1996 to December 1999, data of 3,250 consecutive patients undergoing coronary artery bypass grafting were prospectively entered into the Patient Analysis & Tracking Systems (PATS, Dendrite Clinical Systems, London, UK). Two hundred and fifty-three patients with preoperative serum creatinine more than 150 μmol/L were identified (202 patients on-pump, 51 patients off-pump), and clinical outcomes were analyzed. Serum creatinine and urea, in-hospital mortality, and morbidity were compared between groups. The association of perioperative factors with acute renal failure was investigated by multiple logistic regression analysis.

Results. Preoperative characteristics were similar between the groups. Mean number of grafts was 2.9 ± 0.8 and 2.3 ± 0.8 in the on-pump and off-pump groups, respectively (p < 0.0001). Comparison between groups showed a significantly higher incidence of stroke, inotropic requirement, blood loss, and transfusion of red packed cell and platelets in the on-pump group (all p < 0.05). Postoperative serum creatinine and urea were higher in the on-pump group with a significant difference at 12 hours postoperatively (p < 0.05). Logistic regression analysis identified cardiopulmonary bypass, serum creatinine level 60 hours postoperatively, inotropic requirement, need for intraaortic balloon pump, transfusion of red packed cell, and hours of ventilation as predictors of postoperative acute renal failure.

Conclusions. This study suggests that off-pump coronary artery bypass operations reduce in-hospital morbidity and the likelihood of acute renal failure in patients with preoperative nondialysis-dependent renal insufficiency undergoing myocardial revascularization.     

Multivessel off-pump revascularization in patients with significant left main coronary artery stenosis: early and midterm outcome analysis

BACKGROUND: The presence of significant left main stenosis (> or =50%) has been considered a relative contraindication to the use of off-pump coronary artery bypass (OPCAB) stemming from well-documented hemodynamic perturbations during the displacement of the heart. We examined our experience with patients with critical left main stenosis (LMS) to assess the safety and feasibility of OPCAB in this subgroup. METHODS: Our prospectively updated database was queried to identify all patients with severe left main disease who underwent isolated coronary revascularization between January 1, 1999 and May 31, 2002. This query yielded 234 on-pump and 420 off-pump patients with significant LMS whose clinical information was retrospectively reviewed. RESULTS: The groups were well matched with regard to gender, left ventricular function, surgical priority, and severity of angina. The conventional coronary artery bypass (CABG) group was significantly younger than the OPCAB group and had a higher incidence of a previous myocardial infarction. Patients in the CABG cohort were more likely than OPCAB patients to remain ventilated after 24 hours, require placement of intraoperative or postoperative intraaortic balloon pump, or suffer from postoperative renal failure. There was a decrease in mortality (6.4% vs. 1.9%; p = 0.006) when CPB was eliminated. Intermediate term survival analysis revealed a significant survival benefit in the off-pump group (p = 0.007). CONCLUSIONS: Multivessel off-pump revascularization in patients with severe left main disease is a safe and effective alternative to conventional bypass grafting and conveys a survival benefit.     

Multivessel off-pump coronary artery bypass surgery in the elderly.

OBJECTIVE: Coronary artery bypass grafting in the elderly patient is associated with increased perioperative morbidity and mortality. The avoidance of cardiopulmonary bypass (CPB) in this population is potentially beneficial. We examined our initial experience with off-pump multivessel coronary artery revascularization in patients aged 70 years and older. METHODS: In a consecutive series of 300 off-pump coronary artery bypass (OPCAB) operations performed by a single surgeon between 1996 and 1999, 98 patients were aged 70 years and older. These patients were compared with a consecutive cohort of 497 patients aged 70 years and older operated on with CPB in the same institution from 1995 to 1996, period where OPCAB surgery was not performed in our institution. RESULTS: Patients in the beating heart group were older (75+/-4 vs. 74+/-3 years; P=0.001). Gender distribution and other preoperative risk factors were comparable for the two groups. On average, 3.0+/-0.8 and 2.8+/-0.7 grafts per patient were completed in the OPCAB and the CPB groups, respectively (P=0.007). Perioperative mortality rates (OPCAB group, 3.1%; CPB group, 3.6%), perioperative myocardial infarction (OPCAB, 2.0%; CPB, 5.1%) and neurologic events (OPCAB, 1.0%; CPB, 3.2%) were comparable for the two groups. The incidence of postoperative atrial fibrillation was lower in the OPCAB group (42 vs. 54%; P=0.05). The need for allogenic blood transfusions was significantly less in the OPCAB group (53 vs. 82%; P=0.001). CONCLUSIONS: In patients aged 70 years and older, multivessel OPCAB surgery is associated with lower rates of postoperative atrial fibrillation and reduced transfusion requirements. Multivessel OPCAB in the elderly patient is an acceptable alternative to procedures performed with CPB.     

Multivessel coronary revascularization without saphenous vein: long-term results of bilateral internal mammary artery grafting

When the saphenous vein is absent or inadequate, options for multivessel coronary revascularization include bilateral mammary artery grafting and the use of conduits of unproven durability (arm vein, homologous umbilical vein, prosthetic graft). To evaluate the long-term effectiveness of bilateral mammary artery grafting, we reviewed the cases of 76 consecutive patients with multivessel disease (33 with two-vessel disease, 43 with three-vessel disease) who underwent revascularization with bilateral mammary artery grafts only during the period from 1971 to 1980. No hospital deaths occurred. Thirty-three free and 119 in situ grafts were used. Late follow-up was complete, ranging from 12 to 132 months (mean interval, 67 months) and revealed improvement by at least one New York Heart Association functional class in 59 of 71 survivors. Postoperative arteriograms (mean interval, 26 months) of 55 grafts in 28 patients showed that 49 grafts were patent (89%). Five late deaths (2 noncardiac) occurred. Actuarial survival was 97.2% to seven years and 90.2% at nine years after operation. Bilateral mammary artery grafting yielded excellent graft patency, relief of symptoms, and long-term survival. When saphenous vein is unsuitable for grafting, bilateral mammary artery grafts should be utilized before other conduits are considered.     

Three approaches to surgical treatment of traumatic disruption of the thoracic aorta

Traumatic disruption of the thoracic aorta is said to occur most often near the aortic isthmus because of the mechanisms of aortic injury. Between November 1990 and August 1999, we encountered eight cases of surgical treatment for traumatic injury of the thoracic aorta combined with multi-system injury. In some cases, the injury was located near the aortic isthmus; in such cases, we selected surgical options that made use of three different approaches, namely, media sternotomy, posterolateral left thoracotomy, and anteroaxillal thoracotomy. Each approach has advantages and disadvantages. In selecting an appropriate approach, it is not only necessary to consider the various features of the approach itself, but it is also necessary to consider other factors, such as the assisting apparatus in use, the effects of other injuries sustained by perioperative positioning, safety measures against accidental bleeding during surgery, deployment of the operative field, and potential complications after surgery.