Search

Transcatheter aortic valve replacement (TAVR) has become the preferred intervention for patients with severe aortic stenosis and significant comorbidities. This technique can also be used for failed bioprosthetic valves and is known as the valve-in-valve (ViV) procedure. Placing TAVR in a small bioprosthesis (23 mm) can lead to delayed dysfunction of the prosthetic valve. We present a case of a late explanted ViV 8 years post-initial aortic valve replacement and coronary artery bypass grafting, and 3 years post-ViV procedure in a 76-year-old female. A video of the surgical procedure is provided.

The Impella 5.5 with Smart Assist (Abiomed) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. The use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.

We report a case of Impella 5.5-assisted off-pump coronary artery bypass grafting for acute myocardial infarction with cardiogenic shock. The Impella 5.5 was placed in the left ventricle during the emergent procedure, and an off-pump coronary artery bypass grafting was successfully performed with exposure of all three walls of the heart. Our findings demonstrated the feasibility of off-pump coronary revascularization in three-vessel disease in a patient assisted with an Impella 5.5 percutaneous left ventricular assist device without displacement of the device during the entire perioperative period.

Anomalous coronary arteries are relatively common, occurring in approximately 1.3% of the general population. Most variants of anomalous coronary arteries do not cause disability and have a benign course. Surgery is warranted to alleviate symptoms. However, some anomalies, such as a left coronary artery arising from the right sinus of Valsalva and passing between the great vessels or anomalous left coronary artery arising from the pulmonary artery, are considered malignant as they have been associated with sudden cardiac death or heart failure, and in these cases, surgery is indicated. Coronary artery fistulas are abnormal communications between a coronary artery and another cardiovascular structure. They are relatively rare, and surgical or transcatheter closure may be necessary in patients with large left-to-right shunts and/or regional myocardial ischaemia.

We present a complication following deployment of the MANTA VCD device following a TAVR procedure which resulted in occlusion of the common femoral artery. This was addressed by ballooning the site from the contralateral side which re-established flow. We believe this is the first report to address this kind of complication and may prove useful as more of the MANTA devices are being used in multiple procedures.

Background We present a complication following the deployment of the MANTA vascular closure device (VCD) following a transcatheter aortic valve replacement procedure which resulted in occlusion of the common femoral artery. Aims To address possible complications associated with MANTA VCD. Results This was addressed by ballooning the site from the contralateral side which re-established flow. Conclusion We believe this is the first report to address this kind of complication and may prove useful as more of the MANTA devices are being used in multiple procedures.

Only one case of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus diagnosed and treated during pregnancy has been reported in the literature. In that report, the tumor thrombus extended to the infrahepatic IVC (level II tumor thrombus). In the present case, a 37-year-old woman with lupus anticoagulant antibodies was diagnosed with RCC and IVC tumor thrombus extending to the right atrium (level IV tumor thrombus) at 24 weeks of pregnancy. The fetus was safely delivered by cesarean section at 30 weeks of gestation. At 4 days later, an open right radical nephrectomy and IVC and right atrial thrombectomy were performed on cardiopulmonary bypass (CPB) once the patient’s hemodynamic status had been optimized. Fetal and maternal concerns included the risk of a thromboembolic event (due to increased hypercoagulability from pregnancy, active malignancy, and lupus anticoagulant), intraoperative hemorrhage risk (due to extensive venous collaterals and anticoagulation), and fetal morbidity and mortality (due to fetal lung immaturity). Standardized guidelines for treatment of RCC with or without IVC tumor thrombus during pregnancy are unavailable due to the infrequency of such cases. Treatment decisions are therefore individualized and this case report may inform the management of future patients diagnosed with RCC with level IV tumor thrombus during pregnancy.

Objective: Anomalous left coronary artery from the right coronary sinus (ALCA) is a known cause of sudden death. Surgical correction is recommended for all patients with interarterial course. We describe 2 patients who underwent surgical correction through an off pump- minimally invasive direct coronary artery bypass (MIDCAB) approach with good short and mid-term results.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare clinical entity that occurs in a small subset of acute pulmonary embolism (PE) cases and is surgically cured by pulmonary endarterectomy. We report a case of a 44-year-old female with a complex history of CTEPH treated by thromboendarterectomy who presented with a subdural hematoma while on warfarin. The patient eventually recovered by a multidisciplinary approach, use of inferior vena caval filter, and effective anticoagulation management.

Background: The objective of this study was to investigate the association of the coronary SYNTAX score with the degree of atherosclerosis of the ascending aorta in patients who underwent coronary artery bypass grafting (CABG). Methods: A total of 152 patients (mean age 65 years, 66% male) were analyzed who underwent isolated CABG with both SYNTAX score and the intraoperative 5-point scale grading of the severity of atherosclerosis in the ascending aorta available. The patient were stratified into low, intermediate, and high SYNTAX score groups [≤22 (n=36), 22–33 (n=42), and ≥33 (n=76)]. Results: The mean SYNTAX score was 31±11. Patient demographics and comorbidity were comparable in each group. The prevalence of severe atherosclerosis (Grade ≥III) in the ascending aorta was 17.5% (n=27) in the whole population and was different in each group with higher prevalence in higher score groups (8.3% vs . 9.5% vs . 26.3%, P=0.018). After adjusting for age, sex and other relevant comorbidity, SYNTAX score remained a predictor of severe atherosclerosis [adjusted OR 1.63, 95% CI 1.01–2.62, P=0.046 (per 10 point increase); adjusted OR 5.20, 95% CI 1.15–23.5, P=0.032 (high vs . low score)]. Conclusions: SYNTAX score was associated with the severity of atherosclerosis in the ascending aorta. Patients with high scores have a 5 times higher chance of severe disease compared to patients with low scores and should warrant preoperative and intraoperative comprehensive assessment of the ascending aorta.

Surgical pulmonary embolectomy is one of the treatment options for massive pulmonary embolism. At our institute, we have recently adopted a strategy of video assistance for better visualization and clearance of distal pulmonary emboli. Here, we describe our experience.

Objective It is a common situation after cardiothoracic surgery that a tracheostomy is required for patients who are coagulopathic or on therapeutic anticoagulation. We present our results of percutaneous tracheostomy with uncorrected coagulopathy. Methods Between 2007 and 2012, a total of 149 patients in our Cardiothoracic Surgical Intensive Care Unit underwent percutaneous tracheostomy using the Ciaglia Blue Rhino system (Cook Medical, Bloomington, IN USA). The patients were divided into coagulopathic (platelets, ≤50,000; international normalized ratio of prothrombin time, ≥1.5; and/or partial thromboplastin time, ≥50) and noncoagulopathic groups. Coagulopathy, if present before percutaneous tracheostomy, was not routinely corrected. Results A total of 75 patients (49%) were coagulopathic. Twenty-one patients (14%) had two or more criteria. The coagulopathic patients had a lower platelet count [108 (106) vs 193 (111) (thousands), P < 0.001], with the lowest of 10; higher international normalized ratio of prothrombin time [1.7 (0.6) vs 1.2 (0.1), P < 0.001], with the highest of 5.3; longer partial thromboplastin time [40 (13) vs 33 (7) seconds, P < 0.001], with the longest of 85; and higher total bilirubin [4.6 (7.3) vs 1.9 (3.3) mg/dL, P = 0.005]. Patient demographics and comorbidities were comparable between the groups. No patients had overt bleeding. One coagulopathic patient (1.3%) had clinical oozing treated with packing, as opposed to zero in the noncoagulopathic patients ( P = 1.00). There were no patients with posttracheostomy mediastinitis or late tracheal stenosis. Conclusions Uncorrected coagulopathy and therapeutic anticoagulation did not increase bleeding risk for percutaneous tracheostomy in our cardiothoracic surgical patients.

Pemphigus vulgaris is an autoimmune disorder that causes blistering of the skin and mucous membranes. We present a patient with pemphigus vulgaris who required combined coronary artery bypass grafting and mitral valve repair. The challenges that we faced and modifications to the technique required in this situation are described and reviewed.

OBJECTIVES: Many patients referred for coronary artery bypass surgery (CABG) today have diffusely diseased coronary vessels, and some of them may require coronary endarterectomy to provide adequate revascularization. Most reports of coronary endarterectomy describe an on-pump procedure. As off-pump coronary artery bypass graft has become safer and more routine, there is renewed interest in off-pump coronary endarterectomy. We report on our series of patients who underwent off-pump coronary endarterectomy of the left anterior descending (LAD) artery using an open endarterectomy technique. METHODS: All patients undergoing open heart surgery at The Mount Sinai Medical Center are entered into a state-mandated, audited database. A retrospective review of this database revealed 12 patients between January 2008 and June 2012 who underwent off-pump endarterectomy of the LAD as part of their coronary revascularization. Additional data were collected from a review of the patients’ charts. RESULTS: There were a total of 12 patients, with a mean age of 72 ± 4 years. Nine (75%) were male and 3 (25%) were female. Comorbidities included hypertension in 11 (92%) patients, dyslipidaemia in 10 (83%), diabetes in 8 (67%), renal failure in 6 (50%) and stroke in 1 (8%). The mean number of diseased coronary territories was 3 ± 0.4 (range 2–3), and the mean number of coronary bypass grafts performed was 4 ± 0.8 (range 2–5). Eight patients required transfusion with packed red blood cells (67%). One (8%) patient was converted from off-pump to on-pump. The mean intensive care unit stay was 3 ± 2.8 (range 1–8 days), and the mean hospital length of stay was 15 ± 13 (range 4–54 days). Postoperative follow-up (mean 24 ± 19 months, range 1–53) is complete, and no ischaemic events have occurred in the early and mid-term follow-up period. CONCLUSIONS: We conclude that off-pump endarterectomy of the LAD is a viable option for patients with diffuse LAD disease.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) uses a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. There is renewed interest in minimally invasive coronary surgery and hybrid revascularization. This article describes a standardized approach that has been consistently successful in our institution.

Objective: Anomalous right coronary artery arising from the left sinus (ARCA) is a known cause of sudden cardiac death, particularly in young athletes. Surgery is recommended for all adult patients who are symptomatic or who have evidence of exercise-induced myocardial ischemia. Surgical options include coronary artery bypass grafting (CABG) and anatomic correction by unroofing the ostium or by reimplanting the ostium into the right sinus of Valsalva. We describe the rationale and technique of a minimally invasive right thoracotomy approach for correction of ARCA. Methods: We reviewed all patients with coronary artery disease operated upon at Mount Sinai Medical Center. Between March 2008 and September 2010, 17 patients underwent surgery for anomalous coronary origin from the opposite sinus of Valsalva. Nine of these patients had ARCA. We describe four adult patients with ARCA who were operated upon using a small right anterior thoracotomy incision to perform a right internal mammary artery (RIMA) to right coronary artery (RCA) bypass with ligation of the proximal RCA. This was performed under direct vision and without cardiopulmonary bypass. Results: There were two male and two female patients. Mean age was 55.3 4.8 years (range 50—61 years). Three of the patients manifested chest pain and one each syncope, dyspnea, and palpitations. Two patients had preoperative stress testing that was positive for ischemia. Postoperative follow-up (mean 14 months and range 5—37 months) is complete. All patients are alive and asymptomatic. Conclusions: ARCA can be managed with good early and midterm results using a minimally invasive right thoracotomy approach. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Off pump coronary artery bypass grafting remains an important technique particularly in the care of high-risk patients. Consistently successful adoption of this technique requires a cooperative team approach and standardization across all phases of patient care. This review describes our approach to off pump coronary surgery.

OBJECTIVES We sought to examine contemporary utilization patterns and clinical outcomes in patients with acute myocardial infarction (AMI) requiring intra-aortic balloon pump (IABP) counterpulsation. BACKGROUND Despite increasing experience with and broadened indications for intra-aortic counterpulsation, the current indications, associated complications, and clinical outcomes of IABP use in AMI are unknown. METHODS Between June 1996 and August 2001, data were prospectively collected from 22,663 consecutive patients treated with aortic counterpulsation at 250 medical centers worldwide; 5,495 of these patients had AMI. RESULTS Placement of an IABP in AMI patients was most frequently indicated for cardiogenic shock (27.3%), hemodynamic support during catheterization and/or angioplasty (27.2%) or prior to high-risk surgery (11.2%), mechanical complications of AMI (11.7%), and refractory post-myocardial infarction unstable angina (10.0%). Balloon insertions were successful in 97.7% of patients. Diagnostic catheterization was performed in 96% of patients, and 83% underwent coronary revascularization before hospital discharge. The in-hospital mortality rate was 20.0% (38.7% in patients with shock) and varied markedly by indication and use of revascularization procedures. Major IABP complications occurred in only 2.7% of patients, despite median use for three days, and early IABP discontinuation was required in only 2.1% of patients. CONCLUSIONS With contemporary advances in device technology, insertion technique, and operator experience, IABP counterpulsation may be successfully employed for a wide variety of conditions in the AMI setting, providing significant hemodynamic support with rare major complications in a high-risk patient population.

The Benchmark Counterpulsation Outcomes Registry is a computerized database that incorporates prospectively gathered data on indications for intra-aortic balloon counterpulsation (IABP) use, patient demographics, concomitant medications and in-hospital complications and outcomes. This report summarizes the validation of the Benchmark Registry. Three audits were performed on the Registry data – the first by the sponsor and the second two by independent auditors. The data for categorical variables that could be answered by checking a box were extremely robust, with most items having at least a 95% agreement rate (except catheter size, which had an 82% agreement rate). The data were slightly less robust for quantitative variables that required a written answer (at least an 80% agreement rate). This high agreement rate supports the conclusion that the Benchmark Counterpulsation Outcomes Registry data are generalizable and suggests that the Registry is a powerful tool for tracking the evolving practice of IABP use, including indications, insertion characteristics, duration, complications and outcomes in patients undergoing IABP.

The Benchmark intra-aortic balloon counterpulsation (IABC) registry maintains prospectively gathered clinical information on a large cohort of IABC patients. The purpose of the present report is to compare in-hospital outcomes and complications in patients treated with the newer 8 vs. 9.5 Fr size catheters. Between January 1997 and August 2000, data on 7,078 9.5 Fr and 2,254 8 Fr IABC insertions were submitted to Benchmark. This was not a randomized comparison but rather a posthoc analysis of prospectively gathered data. There was less limb ischemia with the 8 Fr IABC size catheter. There were no significant differences in bleeding or mortality between the two groups. Smaller IABC catheter size is associated with significantly less limb ischemia, especially in higher-risk patients. The large, population-based, ongoing Benchmark registry provides a useful vehicle for outcomes research concerning the evolving practice of IABC.

ORTIC ROOT PATHOLOGIES often require complex surgical repair techniques due to the involvement and manipulation of the coronary arteries. In 1981, Cabrol et al described a technique to reimplant the coronary arteries into the aortic conduit using a Dacron tube graft. 1 In the 1980s and 1990s, the Cabrol technique and its modifications commonly were performed during aortic root surgery, but now are used less frequently due to the development of improved coronary ostial button mobilization techniques. 2 The Cabrol technique still is considered a reasonable alternative when conventional coronary reimplantation is unsuccessful, such as in redo aortic root surgeries. The authors report a rare complication of this technique, in which echocardiography played a crucial role in the rapid and correct diagnosis. CASE REPORT A 43-year-old male (123 kg, 195 cm) was admitted to the authors’ institution for evaluation of progressive dyspnea on exertion and worsening lower extremity edema. The patient had a history of Marfan syndrome, hypertension, and glaucoma. He had undergone an emergent ascending aortic replacement for a Stanford type-A dissection 1 year before the current admission. The perioperative course was complicated by a pulmonary embolism requiring the placement of an inferior vena cava filter and oral anticoagulation with warfarin. During this current admission, the preoperative work-up revealed the presence of a chronic aortic dissection, originating from the aortic arch and extending through the descending thoracic aorta to the level of the inferior mesenteric artery. Additionally, severe aortic regurgitation with a dilated aortic root was reported. Left ventricular function was preserved with no evidence of significant coronary artery disease. Consequently, the patient was scheduled for redo-sternotomy, a Bentall procedure, and a stage-I elephant trunk. After the patient was brought to the operating room, standard ASA monitors were placed and an indwelling left axillary artery catheter was inserted under local anesthesia. The patient was induced with 100 mg of propofol, 1,000 μg of fentanyl, and 10 mg of vecuronium. The airway was secured with a standard 8.0 cuffed endotracheal tube without difficulty. Subsequently, a 9French multi-lumen access catheter was placed into the right internal jugular vein under sonographic guidance. Additional monitoring included a pulmonary artery catheter, transesophageal echocardiography (TEE), cerebral oximetry, bispectral electroencephalography, and temperature measurement in both the nasopharynx and the bladder. General anesthesia was maintained with isoflurane and intermittent boluses of fentanyl, midazolam, and vecuronium. The initial intraoperative TEE showed normal right and left systolic function with an estimated left ventricular ejection fraction of 50%-60% and no regional wall motion abnormalities, severe aortic regurgitation, an aortic root aneurysm measuring 5.2 cm in diameter, and an aortic dissection originating from the arch and extending throughout the descending aorta (Fig 1; Video clip 1). Because of the close proximity of the right ventricle to the sternum, the right axillary artery was cannulated before redosternotomy. The sternum then was divided uneventfully with an oscillating saw, and the cardiac structures carefully dissected. Cardiopulmonary bypass (CPB) was initiated using a double-stage venous cannula through the right atrium. The ascending aortic graft was cross-clamped. Cold blood cardioplegia was administered in an antegrade and retrograde fashion and the patient cooled to 21 degrees Celsius. A modified Bentall procedure was performed using a 27-mm St. Jude Medical mechanical valved graft (St. Jude Medical, Inc., St. Paul, MN). The right coronary button was implanted in a standard fashion into the valved conduit. Because of extreme tissue friability, an 8-mm Dacron graft conduit was anastomosed end-to-end with the left main coronary ostium (hemi-Cabrol technique). The proximal end of the graft then was directed behind the aortic root and connected to the side of the anterior surface of the aortic graft (Figs 2 and 3). The operation then was completed by replacing the aortic arch under deep hypothermic circulatory arrest with a trifurcated graft attached end-to-end to all of the 3 arch branches and end-to-side to the ascending aortic graft. Finally, the ascending aortic graft was anastomosed to the descending thoracic aorta using the elephant trunk technique (a small part of the prosthesis was inserted into the thoracic aorta). After removal of the cross-clamp, the heart was paced using an epicardial ventricular pacing wire. The transgastric shortaxis midpapillary view showed a severely dysfunctional left ventricle with severe hypokinesis in all regions while right ventricular function appeared to be preserved (Video clip 2). Because of the disparity in function of the 2 ventricles, it was concluded that the culprit was most likely a perfusion deficit in

The incidence of esophageal cancer has been steadily increasing in the United States over the past 25 years. Even with standardized surgical techniques, esophagectomy is a complex, multi-phase operation with a wide range of possible complications. The Ivor-Lewis esophagectomy is a commonly used technique where the right gastroepiploic artery (RGEA) becomes the sole source of blood to the stomach. We describe a case of accidental transection of the RGEA which was then re-anastomosed followed by successful use of the gastric conduit. After an acceptable outcome, we suggest that in selected cases anastomosis of the RGEA should be considered.

The left internal mammary artery (LIMA) to the left anterior descending artery bypass remains the gold standard for coronary artery bypass grafting. This review focuses on the three major options for LIMA takedown when using minimal access options to achieve this bypass, namely standard minimally invasive direct coronary artery bypass (MIDCAB), thoracoscopic MIDCAB, and robotically assisted MIDCAB.

The hypothesis tested in these studies was that long-term circulatory support with a nonpulsatile device is safe and causes no end organ dysfunction. An inexpensive, small centrifugal pump with a 7 L/min capacity was implanted in 6 sheep (15 acute implants have previously been reported). The inlet cannula was placed in the left atrium and the outlet graft anastomosed to the descending aorta. A percutaneous cable supplied DC power and heparinized saline (10 ml/hr) for lubrication. Outputs of pump flow, stator, animal core temperature, pump power consumption, and RPM were monitored throughout the course of each experiment. The sheep moved freely within a large pen using an overhead swivel/tether system that carried all input and output lines. Four sheep survived longer than 4 weeks, and the indices of end organ function were analyzed at 28 days. No animal revealed any neurologic dysfunction. Hemoglobin was 9.075 +/- 0.78 g/dl at 28 days, as opposed to 7.475 +/- 0.68 (p = 0.002) before surgery. The blood urea nitrogen was 9.250 +/- 4.57 versus 14 +/- 5.72 mg/dl (p = 0.041), creatinine was 0.775 +/- .10 versus 0.775 +/- 0.05 mg/dl (p > or = 0.999), total bilirubin was 0.425 +/- 0.2 versus 0.225 +/- 0.05 mg/dl (p = 0.092), serum glutamic oxaloacetic transaminase was 74.75 +/- 24 versus 106.25 +/- 15.84 IU/L (p = 0.015), serum glutamic pyruvic transaminase was 36 +/- 28.7 versus 28.3 +/- 5.7 IU/L (p = 0.25), and total protein was 6.675 +/- 0.49 versus 5.47 +/- 0.15 g/dl (p = 0.025). It is concluded that these animals adapted very well to pulseless circulatory support. The results of these studies support the concept of an inexpensive, implantable, centrifugal pump as a ventricular assist device.

REOPERATIVE CORONARY ARTERY bypass grafting (CABG) has decreased significantly in the previous 20 ears, likely because of the increased availability of percutaeous coronary intervention (PCI).1 Reoperative surgery using he classic trans-sternal approach is more technically challengng than primary surgery and is associated with an increased isk of major complications and death.2,3 There is an increased isk of injury to patent bypass grafts, the great vessels, and right entricle during sternal re-entry. Manipulation of the aorta or iseased bypass grafts can precipitate embolization and cause troke or myocardial infarction.2,4,5 Reoperative sternotomy also is associated with prolonged cardiopulmonary bypass (CPB) time, an increased risk of sternal wound infections, and postoperative mediastinitis.2,5 Patients undergoing reoperative sternotomy often have regional ischemia with patent grafts or native vessels to other territories. Although sternotomy provides the best exposure for global access to the myocardium, when only regional access is required, limited-access nonsternotomy approaches are an attractive option. Collectively, these are known as minimally invasive direct CABG (MIDCAB). In addition to the standard monitoring, there are specific anesthetic considerations for nonsternotomy approaches in reoperative coronary surgery. These include the possible use of lung separation techniques and the need for external defibrillator pads. In addition, it is imperative to be prepared for catastrophic events and longer surgical times. An avoidance of CPB affords the benefit of avoiding the coagulopathic derangements that occur on CPB, including platelet, fibrinogen, and coagulation factor dysfunction and dilution. Another common coagulopathic consequence of CPB is fibrinolysis. During off-pump CABG, the use of fibrinolytics usually is not needed. The authors present 3 patients who underwent nonsternotomy approaches to CABG. The surgical approach for each patient was chosen based on vessel involvement.

CASE REPORTA 61-year-old man with a past medical history of systemic hyper-tension presented with a 1-month history of exertional chest pain andshortness of breath. A cardiac nuclear stress test showed exercise-induced anteroseptal, apical, and inferoposterior ischemia with a leftventricular ejection fraction of 36%. Coronary arteriography then wasperformed showing triple-vessel coronary artery disease. There werechronic total occlusions of the right coronary artery and the mid-LAD.The obtuse marginal arteries 1 and 2 also were found to have 50% to60% stenosis. No obvious collaterals were shown on the coronaryangiogram. The patient initially refused coronary artery bypass graft(CABG) surgery.The LAD lesion was crossed with a guidewire, but attempts atangioplasty resulted in an iatrogenic LAD dissection (Fig 1). Theprocedure was aborted, and the patient was referred for urgent surgery.He remained hemodynamically stable. Intraoperatively, the transesoph-ageal echocardiogram (TEE) showed 1 mitral regurgitation and in-ferior septal hypokinesis. Upon inspection of the epicardial surface, themidportionoftheLADhadabluishdiscoloration.AnL15-7ioepiaorticprobe (Phillips Medical, Andover, MA) was placed into a sterile sheathand used to evaluate the vessel. A dissection and intramural hematomawere visualized originating in the midportion of the LAD with no flowin the false lumen (Figs 2 and 3). The LAD was stabilized and opened(Fig 4). The layers of the wall at the site of the arteriotomy werereapproximated to eliminate the false lumen. A left internal mammaryartery to LAD anastomosis then was constructed. Repeat ultrasoundevaluation showed excellent laminar flow through the anastomosis andin the distal LAD (Fig 5). The right internal mammary artery then wasanastomosed to the right coronary artery, and vein grafts were placedto the 2 obtuse marginal arteries. The immediate postprocedure TEEshowed no significant change. The patient remained hemodynamicallystable with no postoperative electrocardiographic or enzymatic changesand had an uneventful postoperative recovery. He remains asymptom-atic 3 years after surgery.DISCUSSION

Vascular complications after removal of an intra-aortic balloon pump (IABP) have been reported to occur in up to 15% of patients. Vasoseal, a vascular hemostasis device (VHD), has been shown to be safe and effective in rapidly achieving hemostasis after a cardiac catheterization or percutaneous coronary intervention. We propose that similar results can be obtained with the VHD when removing an IABP. However, it is necessary to first gain first the experience of deploying the VHD without insertion of a guidewire. We studied 10 patients in whom Vasoseal was utilized after an IABP was removed. The primary endpoint was a composite of major or minor bleeding, infection, and any vascular complication at 7 days. The time to achieve hemostasis was also assessed. There was not a single episode of bleeding, infection, or vascular injury at 7 days. The time to hemostasis ranged between 8 and 17 min (mean, 12.9 min). This VHD can be utilized safely and efficaciously when removing an IABP.

w l E a p a p w d w c i d p w u o p c w i d o d f t fl w c o l f w t T d AGROWING NUMBER of patients are presenting for reoperative cardiac surgery after prior coronary artery byass graft (CABG) surgery.1 One common reason is the need or repeat coronary revascularization because of the progresion of native coronary artery disease or from failure of previus saphenous vein grafts (SVGs). Other indications include ortic valve replacement for aortic stenosis (AS) and mitral alve repair for ischemic mitral regurgitation.1,2 A repeat sterotomy traditionally has been the surgical approach of choice n these patients. However, this becomes more challenging hen a patent left internal mammary artery (LIMA) graft rosses the midline. In this context, sternal re-entry carries a rohibitive risk of injury to the graft, which often is associated ith a fatal outcome. This can be obviated in reoperative mitral alve surgery for which a right thoracotomy approach is a ell-known alternative.1 However, this becomes unfeasible hen concomitant revascularization of the posterolateral wall lso is required. Instead, the left thoracotomy offers considerble utility. Although there are limited case reports and small eries regarding its use in reoperative cardiac surgery,3-9 it emains a versatile approach for a variety of interventions. erein the authors describe 3 scenarios that show its applicaion in both coronary revascularization and valve surgery and ighlight particular features that are germane to each proceure.

We sought to examine contemporary utilization patterns and clinical outcomes in patients with acute myocardial infarction (AMI) requiring intra-aortic balloon pump (IABP) counterpulsation.Despite increasing experience with and broadened indications for intra-aortic counterpulsation, the current indications, associated complications, and clinical outcomes of IABP use in AMI are unknown.Between June 1996 and August 2001, data were prospectively collected from 22,663 consecutive patients treated with aortic counterpulsation at 250 medical centers worldwide; 5,495 of these patients had AMI.Placement of an IABP in AMI patients was most frequently indicated for cardiogenic shock (27.3%), hemodynamic support during catheterization and/or angioplasty (27.2%) or prior to high-risk surgery (11.2%), mechanical complications of AMI (11.7%), and refractory post-myocardial infarction unstable angina (10.0%). Balloon insertions were successful in 97.7% of patients. Diagnostic catheterization was performed in 96% of patients, and 83% underwent coronary revascularization before hospital discharge. The in-hospital mortality rate was 20.0% (38.7% in patients with shock) and varied markedly by indication and use of revascularization procedures. Major IABP complications occurred in only 2.7% of patients, despite median use for three days, and early IABP discontinuation was required in only 2.1% of patients.With contemporary advances in device technology, insertion technique, and operator experience, IABP counterpulsation may be successfully employed for a wide variety of conditions in the AMI setting, providing significant hemodynamic support with rare major complications in a high-risk patient population.

Background . A prospective study was performed assessing the hemodynamic effects of carbon dioxide (CO 2 ) insufflation during endoscopic vein harvesting (EVH) using the Guidant Vasoview Uniport system. Methods . Five hemodynamic and respiratory parameters (end-tidal carbon dioxide, arterial partial pressure of carbon dioxide, mean arterial pressure, mean pulmonary arterial pressure, and cardiac output), were measured in 100 consecutive patients undergoing EVH with CO 2 insufflation. Data were obtained prior to commencement of EVH, 15 minutes after commencement, and 5 minutes after completion of the vein harvesting. Results . No adverse hemodynamic effects were observed during CO 2 insufflation. Specifically, average mean arterial pressure went from 88.77 ± 9.64 to 89.13 ± 8.60 to 88.24 ± 8.71 mm Hg before, during, and after endoscopic vein harvesting ( p = 0.291). Likewise, average mean pulmonary artery pressures were 19.76 ± 4.75, 20.05 ± 4.48, and 20.05 ± 4.62 mm Hg ( p = 0.547); and average cardiac output was 4.25 ± 0.74, 4.22 ± 0.73, and 4.23 ± 0.69 L/min ( p = 0.109) at those three intervals. Additionally, there was no evidence of significant systemic absorption of CO 2 as reflected in average arterial Pco 2 , which remained steady at 37.42 ± 5.19, 37.51 ± 4.59, and 38.10 ± 4.80 mm Hg ( p = 0.217); and average end-tidal CO 2 , which was 32.10 ± 3.66, 32.50 ± 3.47, and 32.38 ± 3.33 mm Hg ( p = 0.335). In a subset of 20 patients with elevated pulmonary arterial pressure (more than 32 mm Hg), there was also no significant change in any of the parameters. Conclusions . Carbon dioxide insufflation during EVH leads to no adverse hemodynamic consequences or systemic CO 2 absorption. The technique appears to be safe and well tolerated.