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Background: Aortic arch replacement is a complicated and high risk procedure. There have been many advances over recent years. We review the changes in our unit's techniques and outcomes over the past 22 years., Methods: Data were collated from databases and medical records for all patients who underwent aortic arch replacement surgery from January 1989 to December 2010. The patients were divided into two groups - Group A (1989-2005) and Group B (2006-2010). Data were analysed to compare early and late series patients' outcomes. Logistic regression was used to identify variables that predicted mortality., Results: Seventy-five eligible patients (56 males; mean age: 57.5 years; Group A: 40, Group B 35) were identified. There were great changes in the technique and the methods of cerebral protection. The overall mortality rate was 30.7% - Group A: 50% and Group B: 8.6% (p<0.001). Overall permanent neurological dysfunction was 23.7% - Group A: 40% and Group B: 11.8% (p=0.012). Cardiovascular disease and circulatory arrest time were significant predictors of mortality., Conclusions: Increased experience and volume and advances in techniques over 22 years have resulted in major improvements in outcomes for patients having aortic arch replacement, allowing the procedure to be performed with greatly improved outcomes., (Copyright © 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier B.V. All rights reserved.)

Background: The effects of off-pump coronary artery bypass (OPCAB) surgery on endothelial cell activation are poorly understood. Endothelial cell adhesion molecules (CAMs) are expressed and released when the endothelium is activated. We compared plasma CAMs (E-selectin, ICAM-1 and VCAM-1) and HUVEC expression of the same CAMs when exposed to plasma taken before, during and after OPCAB or on-pump coronary surgery (CABG)., Methods: Patients undergoing first time CABG (n=10) or OPCAB (n=10) had 6 blood samples taken before surgery and up to 24h post-operatively. Plasma samples were assayed for E-selectin, ICAM-1 and VCAM-1. The same plasma samples were exposed to HUVEC cultures and cell-surface expression of E-selectin, ICAM-1 and VCAM-1 measured. Data are expressed as mean+/-SEM of n subjects., Results: Plasma E-selectin was unchanged. Plasma ICAM-1 and VCAM-1 were elevated 24h post-operatively in both groups (P<0.01), with no differences between the groups. Twenty-four hours post-OPCAB plasma increased basal and IL-1beta induced expression of endothelial VCAM-1 by 133+/-16% and 140+/-27% (P<0.05), respectively. Plasma taken 3h post-CABG decreased endothelial VCAM-1 expression by 76+/-10% (P<0.05). Peri-operative plasma had no effect on endothelial expression of E-selectin or ICAM-1 in either group., Conclusions: OPCAB and CABG with CPB appear to generate qualitatively different inflammatory responses with respect to endothelial activation, which may have clinical implications., (Copyright (c) 2010 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier B.V. All rights reserved.)

Background: With the increasing use of OPCAB, potentially devastating thromboembolic events, including graft thrombosis may become increasingly evident. We present a study of the quantitative and temporal differences of the coagulation system, fibrinolysis and platelet activation after coronary artery surgery with or without cardiopulmonary bypass., Methods: Patients undergoing on-pump CABG (n=10) or OPCAB (n=10) had six blood samples taken before surgery and up to 24h post-operatively. Activation of the coagulation cascade (tissue factor pathway-factor VIIa), endothelial injury (von Willebrand Factor antigen), thrombin generation (prothrombin fragments FI+II), fibrinolysis (decreased plasminogen levels), fibrin degradation (D-Dimer), platelet counts and platelet activation (soluble P-selectin) were quantified., Results: CABG caused earlier and more significant generation of thrombin, however OPCAB caused a late and sustained generation of thrombin. CABG caused intraoperative activation of fibrinolysis and fibrin degradation, however, at 24h these parameters were equally elevated in both groups. Platelet activation was significant in the CABG group, but did not occur in the OPCAB group., Conclusions: Late thrombin generation and reduced fibrinolysis in the presence of intact, functioning platelets may contribute to adverse thromboembolic events after OPCAB surgery. Thromboembolic prophylaxis and anti-platelet therapy may need to be more aggressive after OPCAB surgery.