Composite aortic root replacement using the classic or modified Cabrol coronary artery implantation technique

BACKGROUND: We report in this study our results with composite aortic root replacement (CVR) using the classic or modified Cabrol coronary implantation technique. MATERIAL AND METHODS: From October 2001 to March 2005, 25 patients underwent aortic root replacement. In all cases, the indication for surgery was a degenerative aneurysm with a diameter of more than 6 cm. Seven patients had undergone a previous aortic operation on the ascending aorta. Mean age was 53+/-13 years and 22 patients were male. Mean Euroscore was 5.2+/-2.4. Aortic insufficiency was present in all patients. Two patients had Marfan syndrome. RESULTS: The 30-day mortality was 0%. Two patients required profound hypothermic circulatory arrest. Mean aortic cross-clamp time was 91+/-24 minutes and the mean circulatory arrest time was 24+/-15 minutes. No patients developed a pseudoaneurysm after the operation. CONCLUSION: We conclude that composite aortic root replacement with the classic or modified Cabrol technique results in a low operative mortality. However, it should be only used when a "button" technique is not feasible.     

Valve-sparing aortic root replacement in a patient with retroaortic course of the left circumflex artery

Anomalous origin of the left circumflex artery (LCA) arising from the right coronary sinus was observed in a 45-year-old man with aortic root aneurysm. Valve-sparing aortic root replacement (VSARR) was decided despite the subannular course of the LCA. A modified Tirone David procedure was performed with specific consideration for distribution of the proximal suture line due to the periaortic and subannular course of the LCA. Due to the risk of LCA injury, a coronary artery bypass grafting was performed using the left internal thoracic artery to secure the perfusion of the LCA. The challenging association of aortic root aneurysm and anomalous origin and course of the LCA was managed successfully during VSARR.     

Composite valve-graft replacement of aortic root using separate Dacron tube for coronary artery reattachment

Traditional techniques of aortic root replacement have consisted of separate valve and graft replacement or use of a composite valve graft. These methods have been associated with problems including hemostasis, suture line disruption, and pseudoaneurysm development. They have had limited application in patients without sinus segment enlargement and acute aortic dissection. Between May 21, 1986, and September 7, 1988, 90 patients (73 male and 17 female) underwent replacement of the aortic valve and ascending aorta using a composite valve graft with reattachment of the coronary ostia using a separate, smaller (10 mm) Dacron tube graft. Aortic root replacement was done alone in 41 patients (46%), in association with a concomitant cardiac procedure in 26 patients (29%), and in 23 patients (26%) undergoing cardiac reoperation with and without a concomitant procedure. Aortic arch replacement was required in 25 patients (28%). Profound hypothermia and circulatory arrest were employed in 29 patients (32%). Early survival was 91% (82/90), and there were 4 late deaths. The procedure was found to be hemostatic (only 4 patients [4%] required reexploration for hemorrhage) and durable (no reoperation for pseudoaneurysm formation was necessary).     

Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement.

BACKGROUND: Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement. METHODS: One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%). RESULTS: Global actuarial survival was 76.1% +/- 4.3% for group 1 and 73.7% +/- 3.9% for group 2 at 10 years (p = 0.22). Freedom from reoperation excluding early deaths was 81% +/- 3% for group 1 and 86% +/- 2.2% for group 2 at 10 years (p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 (p = 0.04). CONCLUSIONS: Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.     

Oblique aortic valve replacement and coronary artery bypass grafting for severely calcified narrow aortic root with unstable angina

We report an 84-year-old woman diagnosed with aortic stenosis and regurgitation with a severely calcified narrow aortic root and left main coronary artery trunk stenosis with triple-vessel coronary artery disease. Emergency aortic valve replacement and triple coronary artery bypass grafting were successful. The aortic annulus was small and heavily calcified, and the ascending aorta, the sinus of valsalva and the anterior leaflet of the mitral valve were severely calcified. A St. Jude Medical valve 19A (St. Jude Medical Inc., St. Paul, MN) was inserted obliquely along the noncoronary sinus. This technique is a useful alternative in cases where the patient's life is at risk in situations involving severe extensive calcification of a narrow aortic root.     

An unusual case of periaortitis mimicing aortic aneurysm with coronary artery involvement

We hereby describe a rare case of coronary artery involvement in a patient with periaortitis which was mimicking an aortic aneurysm on computed tomography (CT). This case also highlights the role of CT in differentiating aortic pathologies to guide the management and also the importance of coronary evaluation in such patients.     

Concomitant severe carotid and coronary artery diseases: a separate management or concomitant approach

Objective: To systematically compare outcomes between patients with asymptomatic carotid artery diseases (>80% stenosis) that had undergone staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) vs simultaneous CEA and CABG. Methods: A comprehensive electronic search of MEDLINE, Scopus, EMBASE, and Ovid from their inception up till August 2018 was performed to identify all studies comparing staged CEA followed by CABG to simultaneous CEA and CABG. Primary outcome measure was postoperative stroke, and secondary measures were myocardial infarction (MI) and 30‐day mortality rates. Results: A total of 67 953 patients were analyzed from 11 articles. There was higher rate of previous stroke in the staged cohort (2.64% vs 2.32%; odds ratio [OR], 0.81; 95% confidence interval [CI; 0.66, 0.99]; P = .040). There was no difference in previous MI (P = .57) or unstable angina (P = .08) among both cohorts. Postoperatively, there were higher stroke rates (3.64% vs 2.83%; OR, 0.72; 95% CI [0.62‐0.89]; P < .0001), operative mortality (4.32% vs 3.58%; OR, 0.90; 95% CI [0.83‐0.98]; P = .02), and 30‐day mortality (4.40% vs 3.58%; OR, 0.86; 95% CI [0.78‐0.96]; P = .006) in the simultaneous cohort. However, length of stay was significantly shorter in the simultaneous cohort (11.9 days vs 12.6 days; weighted mean difference 3.14 [0.77‐5.51]; P = .009). There were no significant differences in 1‐year mortality (P = .33), MI rates (P = .08), and rates of transient neurological deficits (P = .06). Conclusion: The results from this study favors staged CEA with CABG with lower incidence of postoperative stroke, operative, and 30‐day mortality. A larger study, ideally a randomized controlled trial, is required to address the superiority of each technique.     

Current status of coronary artery surgery

After a decade of experience with direct coronary artery surgery, certain conclusions have been made regarding its benefits and indications. Conclusion one is that the operation is highly successful in eliminating or alleviating angina; two, it improves exercise tolerance, and three, it prolongs life in patients with significant left main coronary artery disease. The proper selection of patients and the current technique of operation are also presented. Presented at the 79th Annual Congress of the Japan Surgical Society, Sapparo, 1979 May.     

Successful repair of supravalvular aortic stenosis with ostial stenosis of the left coronary artery using Brom’s three patch technique

Stenotic lesion of the left coronary artery is an unnoticed but complicating feature of supravalvular aortic stenosis (SAS). We present successful repair of SAS with left coronary ostial stenosis. A 9-year-old girl was diagnosed as Williams syndrome associated with SAS. She had no symptoms of angina but cardiac catheterization revealed severe stenosis of the left coronary artery ostium. We adopted Brom’s three patch technique, which could enlarge the aortic root and ostial lesion of left coronary artery inclusively. This method is also ideal regarding restoration of the aortic root geometry.     

Surgical treatment of coronary artery aneurysms

Introduction

Coronary artery aneurysms (CAA) are rare. We present our experience with the surgical treatment of patients with CAAs.

Methods

Between March 2000 and October 2016, 15 patients with CAA underwent surgery.

Results

Mean age of patients was 60 ± 16 years and 47% (n = 7) were male. Kawasaki syndrome was present in two (13%) patients and 7% (n = 1) patients had Marfan syndrome. Isolated CAAs were found in 73% (n = 11) and involvement of multiple vessels was present in 27% (n = 4) of patients. Coronary arteries (CA) affected by aneurysms were: 19% (n = 4) left main stem, 33% (n = 7) left anterior descending, 14% (n = 3) left circumflex, and 33% (n = 7) right coronary artery. The majority of patients (93%, n = 14) were operated on pump with a mean cross‐clamp time of 51 ± 23 min. 53% (n = 8) of patients received total arterial CA bypass grafting, while the remaining patients (47%, n = 7) received venous ± internal thoracic artery grafts. Resection/ligation of CAA was performed in 27% (n = 4) of patients. In‐hospital mortality was 0% (n = 0). Follow‐up was complete for 100% of patients and comprised a total of 80 patient‐years. During follow‐up, only one patient (7%) required re‐intervention.

Conclusion

Surgical treatment of CAA has good short‐ and long‐term results.     

Successful coronary artery bypass operation in a SARS-COV-2 infected patient with acute coronary syndrome

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is overwhelming healthcare resources and infrastructure worldwide. Earlier reports have demonstrated complicated postoperative courses and high fatality rates in patients undergoing emergent cardiothoracic surgery who were diagnosed postoperatively with COVID-19. These reports raise the possibility that active COVID-19 might precipitate a catastrophic pathophysiological response to infection in the postoperative period and lead to unfavorable surgical outcomes. Hence, it is imperative to screen patients with SARS-CoV-2 infection before surgery and to carefully monitor them in the postoperative period to identify any signs of active COVID-19. In this report, we present the successful outcome of coronary artery bypass grafting (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection presenting with an acute coronary syndrome and requiring urgent surgical intervention. We employed a thorough strategy to identify subclinical COVID-19 disease, and after confirming the absence of active disease, proceeded with the CABG operation. The patient outcome was successful with the absence of any overt COVID-19 manifestations in the postoperative period.     

Percutaneous coronary intervention compared with coronary artery bypass graft in coronary artery disease patients with chronic kidney disease: a systematic review and meta-analysis

Previous reports of percutaneous coronary intervention versus coronary artery bypass graft outcomes in coronary artery disease patients with chronic kidney disease (CKD) were inconsistent. We evaluated the optimal revascularization strategy for CKD patients. We searched Pub Med, EMBASE, and the Cochrane Central Register of Controlled Trials and scanned the references of relevant articles and reviews. All studies that compared relevant clinical outcomes between percutaneous coronary intervention and coronary artery bypass graft in CKD patients were selected. We defined short-term and long-term all-cause mortality as primary outcome, and long-term incidences of myocardial infarction and revascularization as secondary outcomes. A total of 2235 citations were retrieved, and 31 studies involving 99,054 patients, with 55,383 receiving percutaneous coronary intervention and 43,671 receiving coronary artery bypass graft, were included. In subgroup analyses of dialysis patients receiving percutaneous coronary intervention with stents versus coronary artery bypass graft, CKD patients with multivessel coronary disease, and CKD patients receiving drug-eluting stent versus coronary artery bypass graft, the pooled outcomes revealed that percutaneous coronary intervention possessed lower short-term mortality, but higher late revascularization risk. No significant differences in long-term mortality were observed between the two strategies in these subgroup analyses. In conclusion, in some specific clinical circumstances, CKD patients receiving percutaneous coronary intervention possessed lower short-term all-cause mortality, but higher long-term revascularization risk, than coronary artery bypass graft; long-term all-cause mortality was not different between the two strategies.     

Grafting an anomalous coronary artery: a left anterior descending from the right coronary artery grafted with the right internal thoracic artery

A left anterior descending artery (LAD) arising from the right coronary artery (RCA) or right sinus of Valsalva is an exceedingly rare anomalous variant occurring in 0.03% of the population. We here present the case of an 81-year-old male with severe triple vessel coronary artery disease who was found to have an aberrant LAD arising from the proximal RCA, and was successfully treated with off-pump, total arterial, and complete surgical revascularization.     

A long-term experience with the Cabrol root replacement technique for the management of ascending aortic aneurysms and dissections

BACKGROUND: Little information exists regarding the long-term results of the Cabrol technique. This study aimed at exploring, over a 16-year period, the results of aortic root replacements employing this procedure. METHODS: Between 1986 and 2002 forty-five patients (mean age 58.7 +/- 13.8 years old, 84.4% male) underwent a Cabrol procedure. Aortic dissection was the most frequent cause of aortic disease in this series (n = 17), followed by annuloaortic ectasia (n = 10), atherosclerotic aneurysm (n = 5) and poststenotic dilatation (n = 5). Six patients (13.4%) had undergone a previous aortic operation, 8 (17.7%) had a Marfan syndrome and five (11.1%) underwent concomitant arch replacement. Mean clinical follow-up was 87.3 +/- 24.3 months. Twenty-eight patients (93.3% of survivors) had a transesophageal echocardiography (TEE) performed at a mean of 64 +/- 32 months postoperatively. RESULTS: Early mortality was 20%. It was 9.1% for patients with an ascending aortic aneurysm and 41.2% for dissections (p = 0.026). Independent multivariate predictors of early mortality were: aortic dissection (p = 0.009), emergency operation (p < 0.001), operative year (p = 0.02), cross-clamp time (p = 0.001), and CPB duration (p < 0.001). Actuarial survival was 0.77 +/- 0.06, 0.72 +/- 0.06, 0.59 +/- 0.04 and 0.59 +/- 0.04 at 1, 5, 10, and 16 years, respectively. Multivariate analysis revealed age (p = 0.007), cross-clamp time (p = 0.0006) and CPB duration (p = 0.009) as strong predictors of poor late survival. A periprosthetic jet with significant valve regurgitation was detected by TEE in 3 patients. In one of them, an infected periprosthetic space-right ventricular fistula was demonstrated requiring reoperation. Altogether, freedom from reoperation and endocarditis at 16 years was 0.97 +/- 0.02 and 0.94 +/- 0.03, respectively. CONCLUSIONS: The Cabrol technique demonstrated a nonnegligible incidence of early and long-term complications. It should be rarely used and only when a "button" technique is not feasible.     

支架植入术治疗外伤性冠状动脉夹层并血栓形成致急性心肌梗死1例

患者男,63岁,车祸后全身多处(心前区、右上肢、右下肢及左上肢)疼痛1 h余,伴呼吸困难、全身大汗淋漓、心悸;既往无心脏病、糖尿病、脑血管病史。查体:右上肢、右下肢及左上肢关节活动障碍,右下肢皮下软组织肿胀、瘀青。心电图示V2导联异常Q波,V2、V3导联ST段抬高,Ⅱ、V5、V6导联ST段压低;诊断:前间壁急性心肌梗死。实验室检查:白细胞计数22.59×10⁹/L,D-二聚体13.76μg/ml,纤维蛋白原降解产物50.28μg/ml,降钙素原0.056 ng/ml,超敏肌钙蛋白Ⅰ0.204 ng/ml,肌红蛋白>1000.00 ng/ml,肌酸激酶MB亚型25.13 ng/ml。