Axillary Artery Cannulation for Cardiopulmonary Bypass during Surgery on the Ascending Aorta and Arch

Abstract   Background: Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation. Patients and Methods: Twenty-two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection. Results: The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end-organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications. Conclusions: Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.     

Beating‐Heart Coronary Artery Bypass Grafting With Miniaturized Cardiopulmonary Bypass Results in a More Complete Revascularization When Compared to Off‐Pump Grafting

The technique of miniaturized cardiopulmonary bypass (M‐CPB) for beating‐heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M‐CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump‐related inflammatory response and organ injury. Finally, this technique combines the advantages of the off‐pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M‐CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off‐pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating‐heart CABG, 117 (39%) of them with the use of M‐CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra‐ and early‐postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M‐CPB patients than in patients in the OPCAB group. Beating‐heart CABG with M‐CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating‐heart CABG with the support of a M‐CPB is the operation of choice when total coronary revascularization is needed.     

Minimally Circulatory‐Assisted On‐Pump Beating Coronary Artery Bypass Grafting for Patients With Complex Conditions for Off‐Pump Surgery

Off‐pump coronary artery bypass grafting (OPCAB) in patients with acute myocardial infarction (AMI) is difficult because of circulatory deterioration during displacement of the heart. At our institution, we performed minimally circulatory‐assisted on‐pump beating coronary artery bypass grafting (MICAB) in these patients. During MICAB, support flow was controlled at a minimal level to maintain a systemic blood pressure of approximately 100 mm Hg and a pulmonary arterial systolic pressure of <30 mm Hg, providing optimal pulsatile circulation for end‐organ perfusion and prevention of heart congestion. From September 2006 to March 2012, MICAB was performed in 37 patients. Either emergent or urgent MICAB was performed in 27 patients following AMI because of hemodynamic instability during reconstruction. Elective MICAB was performed in the remaining 10 patients because of dilated left ventricle (LV) or small target coronary arteries. The details of bypass grafts, perioperative renal function, and early and mid‐term morbidity and mortality were compared between the patients who received MICAB and the 37 consecutive patients who underwent OPCAB during the study period at our hospital. The assist flow indices (actual support flow/body surface area) during anastomosis to the left anterior descending artery, left circumflex artery, and right coronary artery were 0.95 ± 0.48 L/min/m², 1.32 ± 0.53 L/min/m², and 1.15 ± 0.47 L/min/m², respectively, in the emergent and urgent patients following AMI, and 0.44 ± 0.39 L/min/m², 1.25 ± 0.39 L/min/m², and 1.14 ± 0.43 L/min/m², respectively, in the elective patients with either dilated LVs or small target vessels. The lowest mixed venous oxygen saturation during pump support in the MICAB group was significantly higher than that in the OPCAB group (83.8 ± 10.8%, 71.6 ± 7.5%, P < 0.001). Comparing MICAB and OPCAB, the median number of distal bypass grafts for both groups was 4 (25th, 75th percentile: 3, 4) (P = 0.558); the complete revascularization rates were 94.6 and 97.3%, respectively (not significant [NS]); the acute patency rates were 98.9 and 99.2%, respectively (NS); and the 30‐day mortality rates were 2.7 and 0%, respectively (NS). No instances of either cerebrovascular complications or newly occurring postoperative renal failure were noted in either group. There were no statistically significant differences between the groups with respect to early and mid‐term results (freedom from all‐cause death: 82.9 vs. 86.5%, respectively, and freedom from cardiac events at 3 years: 96.4 vs. 96.4%, respectively). MICAB is a safe alternative to OPCAB, particularly in patients with AMI and dilated LV. MICAB is associated with high rates of complete revascularization and acute graft patency, adequate preservation of end‐organ function, and early and mid‐term results comparable with those observed following OPCAB.     

Off‐Pump Coronary Artery Bypass Grafting in Patients with End‐Stage Renal Disease on Hemodialysis

Abstract Background: Coronary artery bypass grafting (CABG) for hemodialysis patients is high risk compared with other patient groups. The aim of this study was to analyze the potential benefits of off‐pump CABG for hemodialysis patients. Methods: From April 1994 through December 2000, 26 hemodialysis patients underwent CABG. The off‐pump group consisted of 15 patients operated on without a pump and the on‐pump group consisted of 11 patients operated on with a pump. Results: There was no difference between the two groups with regard to mean age, mean number of diseased vessels and mean number of anastomoses per patient. No patient died in either group during hospitalization. The postoperative complication rate was low in both groups. The postoperative ventilation time was shorter in the off‐pump group (8.5 vs 26.1 hours, p < 0.001, respectively [off‐pump group vs on‐pump group]). The length of ICU stay was shorter in the off‐pump group (1.7 vs 3.5 days, p # 0.01, respectively [off‐pump group vs on‐pump group]). The medial cost was lower in the off‐pump group ($26,200.80 versus $44,024.10 p # 0.0001 respectively [off‐pump group vs on‐pump group]). Conclusions: Off‐pump CABG provided excellent less‐invasive cardiac surgical results for dialysis patients.     

A Prospective Observational Study to Compare Conventional Coronary Artery Bypass Grafting Surgery with Off‐Pump Coronary Artery Bypass Grafting on Basis of EuroSCORE

Abstract Introduction: The use of cardiopulmonary bypass during coronary artery bypass grafting (CABG) surgery has been associated with substantial morbidity. Off‐pump coronary bypass (OPCAB) surgery has become a widely used technique during recent years. EuroSCORE risk scale is the most rigorously evaluated scoring system in cardiac surgery to preoperatively quantify the risk of death and other serious postoperative complications. The aim of this prospective observational study was to compare the mortality and morbidity between OPCAB and conventional CABG in three major preoperative groups as assessed by EuroSCORE. Material and Method: All consecutive patients undergoing isolated coronary artery bypass surgery between January 2003 and December 2004 at Wellington Hospital were included. In this period, 347 patients had conventional CABG and 254 patients had OPCAB. Data were prospectively collected according to Australasian Society of Cardiothoracic Surgeons’ cardiac surgery data set. The preoperative additive EuroSCORE was computed in each patient and the patients were divided into three risk groups. Results of OPCAB and conventional CABG were compared on basis of EuroSCORE group. Results: OPCAB surgery is preferably performed in patients with low‐risk. OPCAB group had lesser number of grafts per patient. When adjusted with risk score, there was no statistically significant difference in mortality in any of the three groups. No significant difference was found for stroke, renal dysfunction, atrial fibrillation, re‐exploration for bleeding, deep sternal wound infection, or pulmonary complications in either of three groups. However, inotropic requirement and requirements of blood products were less in OPCAB group. Conclusion: OPCAB does not offer any significant advantage in terms of mortality and morbidity over conventional CABG. (J Card Surg 2010;25:495‐500)     

Revascularization of Left Anterior Descending (LAD) Artery with In Situ Left Internal Thoracic Artery (LITA) and Coronary‐Coronary Free LITA Grafts: 12‐Year Patency

Abstract Background: We aim to present a patient with coronary‐coronary bypass grafting (CCBG), left anterior descending‐left anterior descending (LAD‐LAD) coronary artery bypass with left internal thoracic artery (LITA), and provide the 12‐year follow‐up angiogram to confirm the longest reported patency. Methods and Results: A 57‐year‐old man with three vessel disease where LAD had multiple lesions was operated on. LITA with pedicle was grafted in situ onto the proximal LAD, and the distal residual segment was used as a free LITA graft to bypass the distal stenosis. The postoperative course was uneventful. The patient has been recently readmitted to our clinic with atypical chest pain. In angiography, all of the bypasses, including the free LITA graft, were patent. Conclusions: We used free LITA graft to bypass the distal lesions of LAD in selected patients as a valid alternative to sequential bypass grafting. To the best of our knowledge, this is the only angiographic view of a CCBG in LAD with LITA graft confirming the long‐term patency.     

MEMRI study ‐ feedback of MEMS dosing history improves adherence to long‐term HAART: adherence is associated with incidence of ‘blips’ in viral load

In routine clinical care we investigated the effect on adherence to HAART of feedback to each patient of graphical plots highlighting recent errors in their dosing history, as compiled electronically using MEMS^®. Patients established on HAART were randomised to receive either active feedback of recent dosing errors (Group A) at clinic visits, or to serve as controls (no feedback) (Group B). After 12 months the control group were un‐blinded and given feedback for a further 6 months. Questionnaires were completed in the waiting room for adherence (GEEMA), Necessity/Concerns, Intrusiveness, Self‐efficacy and Conscientiousness (baseline only). Those declining/excluded from using MEMS were invited to complete baseline questionnaires (Group C). Adherence was estimated from MEMS data as the average proportion of days with at least the prescribed number of doses taken between successive appointments. Drug Holidays (DH) were defined as 3 or more consecutive days without dosing. Of a cohort of 727 ~270 were approached. 180 were randomised. 147 had evaluable MEMS data (68 Group B: 79 Group A). 85 were in Group C (questionnaires only). Baseline characteristics were similar between Group A and B. Group C had a less common past history of AIDS. There was no significant difference in baseline conscientiousness between Groups A and B. Missed doses were much more likely at weekends than weekdays (OR=1.25; [1.15–1.35]). Those taking <95% of prescribed doses during the first interval between visits were defined as poor adherers, which included 69 patients (49%). Their average baseline adherence was 78%. In Group A, average adherence increased (p=0.001) to 90% after the first feedback session, while in Group B average adherence remained stable (p=0.405). In Group B, after un‐blinding and start of feedback, adherence increased to 93%. Patients in Group B were significantly less likely to bring back their MEMS for reading at each appointment (p=0.031). The incidence of viral load ‘blips’ (>50 copies/ml) was significantly increased by DH (p=0.007), frequency of DH (p=0.016), length of DH (p=0.005), and missed doses during the 4 weeks before attendance (p=0.001). Feedback of electronically compiled dosing history data improves adherence to HAART treatment and appears to be an effective intervention for reducing the incidence of viral load ‘blips’. Further results including analysis of the questionnaires will be presented.