Dor operation and quadruple coronary artery bypass grafting combined with endarterectomy

For ischemic cardiomyopathy, both left ventricle (LV) reconstruction and coronary revascularization are necessary. A 58-year-old man with ischemic cardiomyopathy [end diastolic volume index (EDVI)/end systolic volume index (ESVI) = 214/157 ml/m2, ejection fraction (EF) 26%] underwent left ventricular reconstruction using endoventricular circulatory patch plasty (Dor operation) and quadruple coronary artery bypass grafting combined with endarterectomy, which was used for complete coronary revascularization. For the Dor operation, in order to minimize arrest time and to determine the purse-string suture line, palpation of contractility of the left ventricular muscle from inside under the beating heart was performed. And to avoid insufficient postoperative LV volume, a balloon was used. The surgery was performed without blood transfusion or intraaortic balloon pumping (IABP) support. Postoperative cardiac function was excellent (EDVI/ESVI = 128/68 ml/m2, EF 46%).     

Off-pump redo coronary artery bypass grafting

BACKGROUND: Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of reoperation is mainly in reopening the sternum and in the manipulation of the heart and the old grafts. Therefore, off-pump redo coronary artery bypass grafting with a patient-specific approach in selected cases seems an ideal technique. METHODS: Between October 1995 to September 1999, 50 patients with mean age of 61.8+/-8 years underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was carried out in 25 cases through left anterior minithoracotomy. In 1 patient LIMA was grafted on a previous vein graft to LAD, which was critically stenosed proximally but distal anastomosis was patent. In another case LIMA was grafted to Ramus intermedius branch. Midsternotomy approach was used to carry out LAD and right coronary artery grafting in 21 cases. In 2 patients a posterolateral thoracotomy approach was used to bypass obtuse marginal branches without cardiopulmonary bypass; in these cases proximal anastomosis was performed on the descending aorta. RESULTS: Mortality rate was 4% (2 deaths). Two patients sustained perioperative myocardial infarction. No patient was reexplored for hemorrhage and 38 patients did not require homologous blood transfusion. Sixteen patients underwent check angiogram and all of them were found to have patent redo grafts. Cardiac recovery room stay was 22+/-7 hours and hospital stay 5+/-2 days. CONCLUSIONS: In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality and satisfactory graft patency.     

再次冠状动脉旁路移植术42例临床分析

目的 总结再次冠状动脉旁路移植术(CABG)的临床特点及手术效果.方法 对2002年1月至2010年12月连续收治的42例CABG术后患者行再次CABG.其中男性29例,女性13例;年龄46～78岁,平均(61.2±2.1)岁.非体外循环CABG患者31例,心肺转流下CABG患者11例,同期分别行主动脉瓣置换术及主动脉根部替换+右半主动脉弓置换术各1例.结果 全组死亡3例,1例因术中右心室破裂死亡,1例因术后心力衰竭死亡,1例发生肾功能衰竭导致多器官功能衰竭死亡,围手术期病死率为4.8%.其余40例术后呼吸机辅助呼吸时间9～27 h,平均(17±7)h.术后心绞痛均消失,围手术期无心肌梗死发生,顺利恢复出院.术中接受主动脉内球囊反搏6例.术后随访38例,随访时间6～54个月,均无心绞痛发作;12例复查冠状动脉CTA,显示移植血管均通畅.结论 随着手术技巧和围手术期管理的改进,合理采用各种技术,再次冠状动脉旁路移植术可以取得满意疗效.

Abstract：

Objective To determine the clinical characteristics and outcomes of redo CABG.Methods The outcomes of 42 consecutive patients who underwent redo CABG from January 2002 to December 2010 was analyzed.There were 29 males and 13 females,aging from 46 to 78 years old with a mean of(61.2 ± 2.1)years.Off-pump CABG was applied for 31 patients and on-pump CABG for 11 patients.There were 1 patient underwent concomitant aortic valve replacement and 1 patient underwent aortic root and right aortic arch replacement respectively.Results Three patients died of right ventricle rupture,heart failure and multiple system organ failure respectively and the perioperative mortality rate was 4.8%.The post-operatively mechanical ventilation time varied from 9 to 27 h with a mean of(17 ±7)h.There was no residual angina and perioperative myocardial infarction in the remaining patients who were all discharged uneventfully.Intraoperative 6 patients had accepted intraaortic balloon counterpulsation.During the followup from 6 months to 4.5 years for 38 patients,which showed no evidence of recurrent angina and postoperative coronary CT angiography in 12 patients showed the patency of grafts is good.Conclusion Satisfactory outcome of redo coronary artery bypass grafting can be achieved if proper indication were choosed and reasonable management were performed.     

Coronary vasospasm during off-pump coronary artery bypass grafting; report of two cases

Coronary vasospasm is one of the most dangerous and fatal complications of coronary artery bypass grafting (CABG) operation. Our experiences in recent 2 cases happened during off-pump CABG (OPCAB) are presented. Case 1: A 63-year-old male who had 3 vessels disease underwent OPCAB using left internal thoracic artery (LITA) and the radial artery. When the sternotomy was going to be closed, ST elevation of electrocardiogram (ECG) occurred and was followed by ventricular fibrillation. Intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were applied immediately and an additional grafting to first diagonal artery (D 1) was carried out using a saphenous vein. Case 2: A 67-year-old male underwent OPCAB using LITA and the radial artery. ST elevation of ECG suddenly occurred and was followed by complete atrio-ventricular (AV) block when the sternum was closed. IABP and the ventricular pacing were applied immediately. While OPCAB may be less invasive operating method than conventional CABG, we should pay more attention to the coronary vasospasm.     

二次冠状动脉旁路移植术的临床疗效

目的 评价二次冠状动脉旁路移植术的临床疗效.方法 51例病人(占医院同期进行冠状动脉旁路移植术病人的2.5%)进行二次冠状动脉旁路移植术,距首次手术(15.1±5.8)年.10例采用非体外循环冠状动脉旁路移植术(OPCABG),41例采用体外循环冠状动脉旁路移植术(CABG).正中切口43例,左胸侧切口8例.结果 3例行CABG病人手术后呼吸衰竭,需呼吸机辅助.所有病人住ICU(2.2±0.7)天,住院(9.2±2.4)天.术后死亡2例(3.9%),采用OPCABG和CABG者各1例,死亡原因分别为急性心肌梗死、低心排血量综合征和呼吸功能衰竭、重症肺炎.完全再血管化44例,其中行OPCABG者6例,CABG者38例.部分再血管化7例,行OPCABG者4例,CABG者3例.结论 CABG和OPCABG行二次冠状动脉旁路移植术均安全,疗效满意,能达到完全再血管化的目的.     

Minimally invasive direct redo coronary artery bypass grafting.

Redo coronary artery bypass grafting due to graft failure and the progression of new lesions has been increasing in frequency recently. We are often forced to revascularize only the left anterior descending artery (LAD) in very elderly patients with a high risk to median sternotomy. We performed reoperative minimally invasive direct coronary artery bypass grafting (MIDCABG) in seven patients. The target sites were as follows: LAD, 7; first diagonal branch, 1; and the graft material was the left internal thoracic artery (LITA), 7; and saphenous vein graft (SVG), 1. Complete revascularization was accomplished in all patients, by including hybrid therapy in three patients and axillo-coronary bypass grafting with SVGs in two patients. Postoperative angiography showed all patent grafts and all patients were discharged. During a mean follow-up period of 2.4 years (range: 0.5 to 3.5 years), all were free from cardiac events, except for one patient who had recurrent angina due to failure of a previously patent graft 3 years after redo MIDCAB. These results suggest that MIDCABG via left antero-lateral thoracotomy is an effective and safe technique in redo cases, as well as an alternative procedure for hybrid revascularization that combines minimally invasive revascularization of LAD with additional catheter interventional therapy.     

Off-pump redo coronary artery bypass grafting via left thoracotomy.

OBJECTIVE: We evaluated the usefulness of off-pump coronary artery bypass grafting (CABG) via left thoracotomy (LT) in redo coronary revascularization. METHODS: Over the past 23 years, 21 patients (2.3%) underwent redo coronary revascularization in our hospital. The period between the first and the redo surgeries was 9.1+/-4.4 years. They were divided into two groups according to the method of surgical approach in the redo CABG: re-median sternotomy group (RMS group, n=12) and LT group (n=9). RESULTS: In the RMS group, five of 12 patients suffered prolonged postoperative respiratory failure with ventilatory support, and the RMS patients stayed in the hospital for a significantly longer period of time than the LT patients. Four patients (19.0%, 4/21), who were all in the RMS group, died during the hospitalization. In the LT group, there were no hospital deaths and no cases of respiratory failure. CONCLUSION: Redo CABG via LT provided acceptable and satisfactory surgical results. As it is expected that the number of emergency reoperative surgical cases will increase, the LT approach may be useful for rapid exposure of the target coronary artery without causing significant myocardial damage.     

Four cases of third time operation of coronary artery bypass grafting

Reoperative coronary artery bypass operations are increasing in frequency. Consequently, an ever-increasing pool of patients now is being seen with need of coronary revascularization for repeated time. Four cases of second reoperation were retrospectively investigated. Until March 1999, 2,563 cases of isolated coronary artery bypass grafting were done at the Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan. Within those cases, 124 cases (4.8%) were reoperated. And among those 124 cases, 4 cases (3.2%) were secondly reoperated. There were one hospital death and two had a perioperative myocardial infarction. All of them needed intraaortic balloon pump support after operation. Three were discharged with relief of the symptoms. The average age at the primary operation was 51.1 years. All these cases, at the primary operation, no ITA graft was used. Two cases were incompletely revascularized, because of coronary arteries were ungraftable. Both at reoperation and at second reoperation, we are trying to make a complete revascularization by all arterial grafts. But because of limited number of arterial graft at repeated operation, all arterial complete revascularization is not done without difficulty. Therefore it is concluded that saphenous vein graft is still needed at repeated operation.     

Antiphospholipid antibody syndrome in a case with redo coronary artery bypass grafting under cardiopulmonary bypass

(Received for publication on Sept. 17, 1996; accepted on May 12, 1997)     

Operative transluminal coronary angioplasty as an adjunct to coronary artery bypass grafting: report of two cases

Two successful cases undergone operative transluminal coronary angioplasty (OTCA) as an adjunct to coronary artery bypass grafting were reported. We performed retrograde OTCA for LAD with sequential stenotic lesions in one case and for Cx with such lesions in another. Postoperative coronary angiograms showed dilatation of the second stenosis and sufficient flow of the proximal branches to the bypass grafts. For the coronary artery with sequential stenotic lesions, OTCA is a beneficial technique for complete revascularization and shortening of aortic cross clamp time.     

Aortic operation after previous coronary artery bypass grafting

OBJECTIVES: Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection. METHODS: From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0 +/- 44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patent in-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping. RESULTS: The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2 +/- 29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months. CONCLUSION: Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermic perfusion of a patent in-situ arterial graft.     

Aortic operation after previous coronary artery bypass grafting

Objective Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection.Methods: From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0±44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patentin-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping.Results: The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2±29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months.Conclusion: Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermie perfusion of a patentin-situ arterial graft. (Jpn J Thorac Cardiovasc Surg 2006; 54:155-159)     

Left atrial myxoma combined with coronary artery bypass grafting

We experienced 2 cases of surgical treatment for left atrial myxoma combined with coronary artery bypass grafting (CABG) using only in situ arterial grafts. A 58-year-old man who had undergone CABG [left internal thoracic artery (LITA)-right coronary artery (RCA) and saphenous vein graft (SVG)-left anterior descending artery (LAD)] 14 years before was admitted to our hospital, complaining of anterior chest pain. Coronary arteriography demonstrated total occlusion of the LAD and RCA, as well as the stenosis of high lateral branch (HL) and SVG. Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then the right internal thoracic artery (RITA) was anastomosed to the LAD. The postoperative course was uneventful. A 69-year-old woman was admitted to another hospital, complaining of chest pain and dyspnea. Coronary arteriography revealed stenosis of LAD, left circumflex artery (LCx) and HL, as well as left main trunk (LMT). Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then CABG [LITA-HL, gastroepiploic artery (GEA)-RCA and RITA-LAD] was carried out. The postoperative course was uneventful. The priority between CABG and the surgical treatment for cardiac myxoma remains controversial from the point of view of myocardial protection and prevention of systemic embolism of myxomal fragment.     

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting

Open in a separate window OBJECTIVESThe aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events.METHODSA total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan–Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes.RESULTSThe median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37–9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32–9.77; P = 0.013).CONCLUSIONSWhen performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.     

Off-pump coronary artery bypass grafting for single coronary artery; report of a case

A 55-year-old male with single coronary artery complicated by angina pectoris was referred to our department for coronary artery bypass grafting (CABG) . Coronary arteriography could not identify the left coronary orifice. Right coronary arteriography showed that the circumflex branch (Cx) followed the course of the normal right coronary artery (RCA) , and the left anterior descending branch (LAD) followed the Cx. Other findings included 90% stenosis in #4 posterior descending (PD) of RCA. Off-pump CABG was successfully performed to D1 with the left internal thoracic artery graft and to #4PD with the radial artery graft.