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Purpose: A coronary artery aneurysm (CAA) can result in critical cardiac events such as thromboembolic complications or rupture. A saccular CAA located in the left main trunk (LMT) is the most critical form of this pathology and its surgical repair is challenging. We conducted this single-center study to review the surgical outcomes of patients with a saccular CAA in the LMT., Methods: Between May, 2012 and June, 2020, five patients with a saccular CAA in the LMT underwent surgery at our center. The median age at operation was 66.5 (59.7-69) years and the median diameter of the CAA was 13.0 mm (IQR 11-14 mm)., Results: The CAA was fully excluded by patch closure of the LMT orifice and direct closure of the distal LMT, supplemented by coronary artery bypass grafting with the exclusive use of arterial conduits. There was no in-hospital mortality, although one patient suffered graft spasm-related myocardial infarction with complete recovery. Post-operative angiography showed a fully excluded LMT in all patients. There was no mortality or adverse cardiac events during follow-up., Conclusions: Our surgical policy for CAA in the LMT is feasible and safe; however, coronary blood flow is dependent on reliable bypasses., (© 2021. The Author(s).)

Case 1: 17-year-old boy developed severe stenosis at the proximal site of the coronary aneurysm in the left anterior descending artery (LAD). Case 2: 16-year-old boy developed severe stenosis at the proximal site of the coronary aneurysm in the LAD. Case 3: 30-year-old woman developed severe stenosis of the distal portion of the coronary aneurysm in the LAD. Minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal thoracic artery harvest was successfully performed without cardiopulmonary bypass in these three young patients with Kawasaki disease. This is the first case report of robot-assisted MIDCAB for Kawasaki disease.

Background: Although coronary artery bypass grafting (CABG) is the preferred choice for advanced Kawasaki disease (KD)-associated coronary artery disease, graft design such as number of grafts or type of conduits has not been fully established. We reviewed a series of patients who underwent single or multiple CABG for coronary artery disease of KD sequelae to investigate the optimum revascularization strategy., Methods: We enrolled a consecutive series of 102 CABG surgeries in 92 patients during the last 36 years. Mean patient age at CABG was 14.9 ± 10.4 years. Internal thoracic artery, radial artery, and gastroepiploic artery were used in 100 (98%), 18 (15%), and 4 (4%) cases, respectively. Patients were divided into 2 groups by single (n = 53) or multiple (n = 49) CABG., Results: Actuarial survival was 93% in single CABG and 91% in multiple CABG at 30 years (P = .71). There was no in-hospital mortality, but 6 deaths occurred long term, with no significant difference between the groups. Freedom from cardiac events was 45.2% in single CABG and 68.5% in multiple CABG at 25 years (P = .228), and reintervention to the left anterior descending (LAD) artery territory was the most common event. Graft patency of the internal thoracic artery-LAD artery graft was 81% in single CABG and 85% in multiple CABG at 25 years. Patency of the radial artery in the non-LAD artery territories was significantly greater than that of the saphenous vein graft at 10 years (91% vs 46%, P = .013)., Conclusions: Multiple CABG using arterial conduits is feasible, safe, and therapeutically effective long term for patients with advanced KD-associated coronary artery disease., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In patients with an atrial septal defect (ASD) and left ventricular (LV) dysfunction associated with coronary artery disease (CAD), to avoid the development of acute left heart failure (HF) and an increase in myocardial oxygen consumption following ASD closure, it is conceivable that coronary artery revascularization should be performed prior to ASD closure. We report the case of a 67-year-old man with a large secundum ASD and LV ejection fraction of 15.6% resulting from severe ischemic cardiomyopathy and triple-vessel CAD, both of which contributed to biventricular HF characterized by high left-to-right shunt (Qp:Qs of 7.1:1) and low systemic cardiac output. After evaluating his hemodynamics and biventricular function with cardiac catheterization and cardiovascular magnetic resonance imaging, we successfully conducted an inverse, stepwise strategy of transcatheter ASD closure using anti-congestive therapies, intraaortic balloon pumping, and subsequent balloon occlusion testing, followed by on-pump beating-heart coronary artery bypass grafting.

Background: The best management strategy for patients with coronary disease and mild to moderate AS requires the clinician to consider the operative risks of isolated coronary artery bypass grafting (CABG) against the risks of untreated aortic stenosis (AS)., Methods: Between 2000 and 2014, isolated off-pump CABG (OPCAB) was performed in 2023 patients. Of these patients, 103 presented with mild or moderate AS (mean age 72.7±6.3 years; 23 females), 96 (93.2%) presented with mild AS and seven (6.8%) presented with moderate AS. We compared the long-term outcome of these 103 patients undergoing isolated OPCAB with 13 patients who presented with moderate AS and coronary artery disease (CAD) and underwent concomitant aortic valve replacement (AVR) and CABG during the same period., Results: Mean number of distal anastomoses was 3.7±0.9 per patient, and early graft patency was 98.9% (365 of 369 grafts). No patient required on-pump CABG or concomitant AVR. There were two in-hospital deaths (1.9%). Cumulative 5- and 10-year survival rates were 78.3% and 56.6%, respectively. The respective 5- and 10-year rates of freedom from severe AS were 38.1% and 0.0% in patients with moderate AS, and 73.2% and 65.4% in patients with mild AS (log-rank test, p<0.01). Twelve patients required subsequent AVR, including eight who underwent transcatheter AVR. There were no significant differences between patients undergoing isolated OPCAB and patients undergoing concomitant AVR and CABG according to cumulative survival rate (log rank test, p=0.78) and freedom from major adverse cardiac and cerebrovascular events (log rank test, p=0.59)., Conclusions: Isolated OPCAB is a reasonable staged strategy in coronary disease with mild AS, as the less invasive option of transcatheter AVR is available later if required., (Copyright © 2016. Published by Elsevier Ltd.)

Background: The efficacy and prognosis of percutaneous coronary intervention (PCI) as secondary revascularization in patients with previous coronary artery bypass graft surgery remain uncertain., Methods and Results: We retrospectively evaluated 434 consecutive patients with previous coronary artery bypass graft surgery hospitalized for PCI between 2004 and 2011 (men 84%, age 71 (interquartile range, 66-76) years) and calculated the coronary artery bypass graft Synergy Between Percutaneous Coronary Intervention With Taxus score (CSS) before (baseline CSS) and after PCI (post-PCI CSS). Patients were divided into 2 groups based on median post-PCI CSS: low-score (≤23; n=217) and high-score groups (>23; n=217). Major adverse cardiovascular events (MACE) were defined as the composite of cardiovascular death, myocardial infarction, and unplanned repeat revascularization for myocardial ischemia. The median baseline and post-PCI CSS were 30 (interquartile range, 21-40) and 23 (interquartile range, 14.5-33.5), respectively. During a median follow-up of 69 months, the prevalence of MACE and cardiac death differed significantly between the 2 post-PCI CSS groups (MACE: low, 13.8%; high, 28.6%; P<0.001; cardiac death: low, 6.2%; high, 16.7%; P=0.002). In multivariable analysis, the high post-PCI CSS divided by the median was associated with substantially greater cumulative MACE (hazard ratio, 2.09; 95% confidence interval, 1.31-3.34; P=0.002) and cardiac death (hazard ratio, 2.02; 95% confidence interval, 1.03-3.98; P=0.042) compared with the low post-PCI CSS. Net reclassification improvement analysis revealed that post-PCI CSS resulted in significantly improved prediction of MACE and cardiac death compared with baseline CSS., Conclusions: In this external validation study, the CSS was a potential prognostic factor after subsequent PCI, even for previous coronary artery bypass graft surgery patients., (© 2016 American Heart Association, Inc.)

Background: Chronic postsurgical pain (CPSP) worsens patients' mortality, morbidity, and quality of life. Cardiopulmonary bypass is mandatory for cardiac surgery, but it induces intense inflammation. The presence of inflammation is a crucial part of pain sensitization. An extreme inflammatory response due to cardiopulmonary bypass might cause a high prevalence of CPSP after cardiac surgery. We hypothesized that the prevalence and severity of CPSP are higher in patients after on-pump coronary artery bypass graft (CABG) surgery than in those after off-pump CABG surgery. Methods: This prospective, observational study was performed on a cohort from a randomized trial (on-pump CABG: 81 patients, off-pump CABG: 86 patients). A questionnaire about the severity of surgical wound pain that evaluated pain with the numerical rating scale (NRS) was filled out by the patients. NRS responses for current pain, peak pain in the last 4 weeks, and average pain in the last 4 weeks were evaluated. The main outcomes were the severity of CPSP as evaluated using the NRS and the prevalence of CPSP. CPSP was defined as pain with an NRS score > 0. Differences in severity between groups were analyzed using multivariate ordinal logistic regression models adjusted for age and sex, and differences in prevalence between groups were analyzed using multivariate logistic regression models adjusted for age and sex. Results: The questionnaire return rate was 77.0%. During a median follow-up of 17 years, 26 patients complained of CPSP (on-pump CABG: 20 patients, off-pump CABG: 6 patients). Ordinal logistic regression showed that the NRS response for current pain (odds ratio [OR] 2.34; 95% CI 1.12–4.92; P = 0.024) and the NRS response for peak pain in the last 4 weeks (OR 2.71; 95% CI 1.35–5.42; P = 0.005) were significantly higher in patients who underwent on-pump CABG surgery than in those who underwent off-pump CABG. Logistic regression showed that on-pump CABG surgery was an independent predictor of CPSP (OR 2.59; 95% CI 1.06–6.31; P = 0.036). Conclusions: The prevalence and severity of CPSP are higher in patients with on-pump CABG surgery than in those with off-pump CABG surgery. [ABSTRACT FROM AUTHOR]

Objectives: We retrospectively evaluated graft patency in patients who underwent no-touch aortic arterial off-pump coronary artery bypass grafting to determine the optimal selection of target vessels for improved graft patency of composite and sequential radial artery I-grafts.Methods: The radial artery was anastomosed to the end of an in situ internal thoracic artery and was sequentially anastomosed to non-left anterior descending arteries. This composite graft was defined as an "I-graft." We evaluated 145 I-grafts with 2, 3, or 4 sequential anastomoses (437 graft segments). A graft segment with the final distal anastomosis of every I-graft was defined as the last graft segment (LGS). When a sequential anastomosis was initiated from the left coronary branch, the I-graft assumed a clockwise course (69.0%). When a sequential anastomosis was initiated from the right coronary branch, the I-graft assumed a counterclockwise course (31.0%).Results: On multivariable analysis, right coronary branch (P < 0.001), moderately stenotic (50-75%) target vessel (P = 0.004), and LGS with moderately stenotic target vessel (P = 0.005) were predictors of mid-term graft occlusion. In situations where the LGS was anastomosed to a severely stenotic target vessel (>75%) with a clockwise course, when the number of moderately stenotic target vessels among sequential graft segments was 0, 1, or ≥2, the mid-term graft patency rates of I-grafts were 94.0%, 86.0%, and 81.4%, respectively.Conclusions: The selection of target vessels for severely stenotic lesions among sequential graft segments and the clockwise course enhance the mid-term graft patency of sequential radial I-grafts. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated the feasibility of off-pump minimally invasive direct coronary artery bypass (MIDCAB) in combination with robotic harvesting of the left internal mammary artery (LIMA). Methods: Since 2004, 33 patients [average age, 64 years; 27 males (82 %)] have undergone MIDCAB with robotic LIMA harvesting performed through the fourth or fifth intercostal space with guidance by enhanced computed tomography (CT). Results: No deaths or major adverse cardiac events occurred. Robotic LIMA harvesting was completed in 30 cases (91 %), while three cases (9 %) required conversion to a median sternotomy due to bleeding. The risk of LIMA injury significantly increased with age ( p = 0.0012). For the 30 successful cases, the average harvest time was 68 min, and the average intraoperative blood loss was 306 ml, with only three patients (9 %) requiring a transfusion. The graft flow was measurable in all cases (average, 34 ml/minute). All grafts were shown to be patent in postoperative evaluations, although CT revealed that the LIMA in one patient was anastomosed to an untargeted artery. Conclusions: Off-pump MIDCAB in combination with robotic harvesting of the LIMA is a reasonable and less invasive procedure than the standard procedures. Potential problems include difficulty controlling bleeding from the graft, especially in elderly patients, and proper identification of the target artery. [ABSTRACT FROM AUTHOR]

Cardiac allograft vasculopathy (CAV) is a major cause of mortality after transplantation. We treated a 44-year-old female with off-pump coronary artery bypass grafting (OPCAB) 4 years after heart transplantation. Annual examinations, including coronary angiography and intravenous ultrasound (IVUS), revealed a severe lesion in the left main trunk. The left internal mammary artery was successfully anastomosed to the left anterior descending artery in an off-pump manner. To ensure that patients have a good long-term outcome after heart transplantation, routine examinations, including IVUS, are crucial, because of the nature of CAV. OPCAB is a good option for a left main trunk lesion due to CAV. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the early and intermediate-term outcomes of patients who underwent concomitant off-pump coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR). Between January 2014 and June 2021, 49 patients underwent concomitant off-pump CABG and TAVR via median sternotomy (TAVRCAB group) and 143 underwent concomitant on-pump CABG and surgical aortic replacement. Of the 143 patients who underwent on-pump surgery, 80 (SAVRCAB group) were eligible for comparison. The composite event included all-cause death, heart failure rehospitalisation, repeat revascularisation, brain infarction, and repeat aortic valve replacement. The Society of Thoracic Surgeons' predicted risk for mortality and age were higher in the TAVRCAB group than in the SAVRCAB group (7.1% vs 3.1% [p<0.001]; 81 yrs vs 75 years [p<0.001], respectively), while the surgical time was shorter (289 min vs 352 min; p<0.001). There was no conversion to on-pump surgery in the TAVRCAB group. The postoperative maximum creatinine kinase-MB value was lower in the TAVRCAB group. There was no deep sternal wound infection or repeat revascularisation in either group. Hospital death and brain infarction developed in one patient (1.3%) each in the SAVRCAB group, but in no patients in the TAVRCAB group. The rates of freedom from the composite event were similar between the two groups during the follow-up period. Concomitant off-pump CABG and TAVR would be a less-invasive alternative procedure for treating intermediate or high surgical risk patients with aortic stenosis and coronary artery disease unsuitable for percutaneous coronary intervention. [ABSTRACT FROM AUTHOR]