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Background Del Nido (DN) cardioplegia, a calcium-free, hyperkalemic solution containing lidocaine and magnesium has been developed to help reduce intracellular calcium influx and the resulting myocyte damage in the immediate postischemic period following cardiac arrest. DN cardioplegia has been used for pediatric cardiac surgery but its use in complex reoperative surgery has not been studied. We specifically report the outcomes of patients undergoing reoperative cardiac surgery after previous coronary artery bypass grafting with a patent internal mammary artery (IMA). Methods Patients undergoing reoperative cardiac surgery with prior coronary bypass grafting surgery were studied between 2010 and 2013. Fourteen patients were identified who required continued retrograde cardioplegia administration. In all cases, an initial antegrade dose was given, followed by continuous retrograde administration. Demographics, co-morbidities, intra-operative variables including cardioplegia volumes, post-operative complications, and patient outcomes were collected. Results The mean age of all patients was 73.3+/−6.7 years, and 93 % were male. Aortic cross clamp time and cardiopulmonary bypass times were 81+/−35 and 151+/−79 mins, respectively. Antegrade, retrograde and total cardioplegia doses were 1101+/−398, 3096+/−3185 and 4367+/−3751 ml, respectively. An average of 0.93+/−0.92 inotropes and 1.50+/−0.76 pressors were used on ICU admission after surgery. ICU and total hospital lengths of stay were 5.5+/−7.4 and 9.6+/−8.0 days, respectively. Complications occurred in two patients (14 %) (pneumonia and prolonged mechanical ventilation) and new arrhythmias occurred in five patients (36 %) (four new-onset atrial fibrillation and one pulseless electrical activity requiring 2 min of chest compression). No perioperative myocardial infarctions were noted based on electrocardiograms and cardiac serum markers. Postoperatively, left ventricular function was preserved in all patients whereas two patients (14 %) had mild decrease in right ventricular function as assessed by echocardiography. No mortality was observed. Conclusion Del Nido cardioplegia solution provides acceptable myocardial protection for cardiac surgery that requires continuous retrograde cardioplegia administration. DN cardioplegia’s administration in a continuous retrograde fashion with a patent IMA is believed to provide adequate myocardial protection while avoiding injuring the IMA through dissection and clamping.

Cytomegalovirus (CMV) enteritis post coronary artery bypass grafting (CABG) has been previously reported but never in an immunocompetent patient not on steroid therapy preoperatively.

Coronary artery bypass grafting (CABG) remains an index procedure in cardiac surgery. Despite the increasing use of arterial conduits, the great saphenous vein remains the most widely used conduit due to its ease of harvest, availability and versatility. Traditional open harvesting technique (OVH) is associated with significant wound - related morbidity and therefore an endoscopic minimally invasive harvesting technique is increasingly employed. In our institution, endoscopic vein harvest (EVH) is now performed as a routine and here we report our mid-term results.

Bleeding complications and perioperative cardiovascular events are strongly influenced by the management of antithrombotic therapy before and after Coronary Artery Bypass Grafting (CABG). Early thrombosis is a major cause of vein graft attrition after CABG1 with occlusion rates ranging between 5 - 26% 2. There is scarce evidence in dual antiplatelet therapy post elective CABG.

Acute kidney injury (AKI) following coronary artery bypass grafting (CABG) results in significant morbidity, mortality and prolonged stay on the cardiothoracic ICU. We sought to determine the incidence of AKI in our cardiothoracic centre, hypothesizing a higher occurrence in patients undergoing CABG using cardiopulmonary bypass (ONCAB) compared with off-pump (OPCAB) surgery [1].

We report a case of a 41-year-old Indian man who initially underwent an emergency coronary artery bypass grafting surgery (CABG) after presenting with an anterolateral myocardial infarction. Post-operatively he developed progressively worsening symptoms of right heart failure with increasing abdominal distension and lower limb swelling. Clinically, the patient was in NYHA class 4 heart failure. He was admitted multiple times for the treatment of his heart failure, which was recalcitrant to diuretic therapy. He subsequently underwent an MRI scan, which revealed near transmural myocardial infarction involving mainly the left side of the heart. The right atrium and ventricle were grossly dilated, with moderate to severe right ventricular systolic dysfunction. A sinus venosus atrial septal defect with right-sided partial anomalous pulmonary venous drainange (PAPVD) was noted. He subsequently underwent surgery to repair the sinus venosus atrial septal defect (ASD) as well as re-route the PAPVD to the left atrium (LA). He was discharged on post-operative day 19 with oral diuretics. On follow-up at 1 month, the patient's symptoms had resolved and his clinical status corresponded to NYHA class 1–2.

Early extubation post coronary artery bypass grafting does not increase perioperative morbidity and reduces the length of stay (LOS) in the ICU and in hospital [1]. Use of low-dose opioid- based general anaesthesia and time-directed protocols for fast- track interventions does not increase mortality or postoperative complications in low-moderate-risk patients and has been found to have a reduced time to extubation and shortened ICU stay [2]. Our mean time to extubation is 6 hours, although patients are assessed to be safe to be weaned from mechanical ventilation at 2 hours following arrival in the ICU. This study aims to identify factors that delay extubation in patients undergoing routine cardiac surgery at our institution.

Both ACTH and cortisol are secreted in a diurnal rhythm. Underlying this is an ultradian rhythm of discrete pulses [1] as a result of the feedforward:feedback interactions between cortisol and ACTH [2]. These pulses are critical for normal function; pulsatile and constant infusions yield different transcriptional responses [3] and patients on optimal (nonpulsatile) glucocorticoid replacement have twice the age-related mortality of the general population [4]. We have now characterised the ultradian rhythm and pituitary-adrenal interaction of patients undergoing coronary artery bypass grafting (CABG).

Background The saphenous vein is still the most widely used conduit in CABG surgery despite its poor long term patency. In the 1990’s a new No-touch technique for saphenous vein graft harvesting for CABG was introduced where the vein graft is harvested with a pedicle of surrounding tissue. With the No-touch technique the vein graft does not go into spasm and the vessel wall does not have to be exposed to distension-induced trauma. A previous randomized trial has shown a significantly higher patency rate for vein grafts harvested with the No-touch technique compared to vein grafts harvested with conventional technique and the patency for No-touch vein grafts was comparable to the patency of the left internal thoracic artery, 8.5 years after surgery. The aim of this study was to evaluate whether the increased patency rate for No-touch vein grafts is reflected in clinical outcome.

Results The two groups were comparable in terms of age, gender, body mass index, smoking habit. The results of the research showed a clear improvement in health-related quality of life of patients in both groups who underwent CABG, as compared to that prior to the intervention. But there were no statistically significant differences between the group that underwent conventional CABG and the group that underwent off-pump CABG, which is consistent with the existing literature. The index of SF-6D utility is highly correlated with CROQ when compared with the other utilities indexes and we propose its use in patients with coronary artery disease. Conclusion CABG modifies and improves the clinical presentation and patient’s quality of life, with no difference in health-related quality of life between off-pump and conventional CABG.

Background The relative value of off-pump coronary bypass (OPCAB) surgery as compared to conventional coronary artery bypass operation is still debated. We started a prospective study in 2000 with the aim of using exclusively OPCAB for surgical myocardial revascularization in a single center. The present report analyzes the 13-years results of this approach in a large consecutive patient population.

Background The greater saphenous vein is commonly used in coronary revascularization. Beside classical methods of vein harvesting, endoscopic technique is applied. The introduction of endoscopic vein harvesting remains still controversial and therefore needs some more data resulting from application of this method. This study was performed to investigate the influence of endoscopic and open saphenous vein harvesting techniques on shortand mid-term effects on the lower limb after coronary artery bypass grafting.

Metformin, widely used as an antidiabetic drug, activates the AMP activated protein kinase, a key regulator of the metabolism providing protection under fuel deficiency. Chronic metformin therapy has been shown in long-term follow-up clinical studies to reduce cardiovascular mortality [1]. In animal experiments, acute metformin pretreatment has been shown to reduce ischemia-reperfusion injury on cardiomyocytes [2]. We want to evaluate whether outcomes are affected in coronary artery bypass grafting (CABG) surgery.

Patients with chronic kidney disease (CKD) have been largely excluded from clinical trials of off-pump coronary artery bypass grafting (OPCAB). We sought to determine if the pump status affected outcomes in patients with CKD.

Background In coronary artery bypass grafting surgery, arterial conduits are preferred because of more favourable long-term patency and outcome. Anyway the greater saphenous vein continues to be the most commonly used bypass conduit. Minimally invasive endoscopic saphenous vein harvesting is increasingly being investigated in order to reduce the morbidity associated with conventional open vein harvesting, includes postoperative leg wound complications, pain and patient satisfaction. However, to date the short and the long-term benefits of the endoscopic technique remain controversial. This study provides an interesting opportunity to address this gap in the literature. Methods/Design Endoscopic Saphenous harvesting with an Open CO2 System trial includes two parallel vein harvesting arms in coronary artery bypass grafting surgery. It is an interventional, single centre, prospective, randomized, safety/efficacy, cost/effectiveness study, in adult patients with elective planned and first isolated coronary artery disease. A simple size of 100 patients for each arm will be required to achieve 80% statistical power, with a significant level of 0.05, for detecting most of the formulated hypotheses. A six-weeks leg wound complications rate was assumed to be 20% in the conventional arm and less of 4% in the endoscopic arm. Previously quoted studies suggest a first-year vein-graft failure rate of about 20% with an annual occlusion rate of 1% to 2% in the first six years, with practically no difference between the endoscopic and conventional approaches. Similarly, the results on event-free survival rates for the two arms have barely a 2-3% gap. Assuming a 10% drop-out rate and a 5% cross-over rate, the goal is to enrol 230 patients from a single Italian cardiac surgery centre. Discussion The goal of this prospective randomized trial is to compare and to test improvement in wound healing, quality of life, safety/efficacy, cost-effectiveness, short and long-term outcomes and vein-graft patency after endoscopic open CO2 harvesting system versus conventional vein harvesting. The expected results are of high clinical relevance and will show the safety/efficacy or non-inferiority of one treatment approach in terms of vein harvesting for coronary artery bypass grafting surgery. Trial registration www.clinicalTrials.gov NCT01121341.

Objectives Preventing stroke after coronary artery bypass grafting (CABG) remains a therapeutic goal, due in part to the lack of identifiable risk factors. The aim of this study, accordingly, was to identify risk factors in CABG patients with a previous history of stroke. Methods Patients with a history of stroke who underwent CABG at Beijing An Zhen hospital from January 2007 to July 2010 were selected (n = 430), and divided into two groups according to the occurrence of postoperative stroke. Pre-operative and post-operative data were retrospectively collected and analyzed by univariate and multivariate logistic regression analyses. Results Thirty-two patients (7.4%) suffered post-operative stroke. Univariate analysis identified several statistically significant risk factors in the post-operative stroke group, including pre-surgical left ventricular ejection fractions (LVEF) ≤50%, on-pump surgery, post-operative atrial fibrillation (AF), and hypotension. Multivariable analysis identified 4 independent risk factors for recurrent stroke: unstable angina (odds ratio (OR) = 2.95, 95% CI: 1.05-8.28), LVEF ≤50% (OR = 2.77, 95% CI: 1.23-6.27), AF (OR = 4.69, 95% CI: 1.89-11.63), and hypotension (OR = 2.55, 95% CI: 1.07-6.04). Conclusion Unstable angina, LVEF ≤50%, post-operative AF, and post-operative hypotension are independent risk factors of recurrent stroke in CABG patients with a previous history of stroke.

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) surgery is associated with increased postoperative morbidity and mortality. The aim of this study was to apply the RIFLE (risk (R), injury (I), failure (F), loss (L) and end-stage kidney disease (E)) criteria in patients after CABG surgery, to identify intraoperative risk factors for occurrence of AKI and to analyze the impact of AKI on mortality.

Coronary artery bypass grafting (CABG) has traditionally been performed with the use of cardiopulmonary bypass (ONCAB). CABG without cardiopulmonary bypass (OPCAB) might reduce the number of complications. Thus, this study aims to compare between on-pump and off-pump surgery concerning postoperative morbidity and mortality, also to evaluate 6-month graft patency in Egyptian patients.

This study compared the effect on renal function of flucloxacillin and vancomycin antibiotic prophylaxis for elective first-time coronary artery bypass grafting (CABG) surgery, using both direct biochemical markers and indirect clinical outcome measures. Recent evidence has suggested that vancomycin may be nephrotoxic in patients undergoing cardiac surgery.

Background Cross-clamp fibrillation is a well established method of performing coronary grafting, but its clinical effect on the myocardium is unknown. We sought to measure these effects clinically using the Khuri Intramyocardial pH monitor. Methods 50 episodes of cross-clamping were recorded in 16 patients who underwent CABG with crossclamp-fibrillation. An Intramyocardial pH probe measured the level of acidosis in the anterior and posterior myocardium in real-time. The pH at the start and end of each period of cross-clamping was recorded. Results It became very apparent that the pH of some patients recovered quickly while others entirely failed to recover. Thus the patients were split into 2 groups according to whether the pH recovered to above 6.8 after the first crossclamp-release (N = 8 in each group). Initial pH was 7.133 (range 6.974–7.239). After the first period of crossclamping the pH dropped to 6.381 (range 6.034–6.684). The pH in recoverers prior to the second XC application was 6.990(range 6.808–7.222) compared to only 6.455 (range 6.200–6.737) in patient's whose myocardium did not recover (P < 0.0005). This finding was repeated after the second XC release (mean pH 7.005 vs 6.537) and the third (mean pH 6.736 vs 6.376). However prior to separation from bypass the pH was close to the initial pH in both groups (7.062 vs 7.038). Conclusion Crossclamp fibrillation does not result in reliable reperfusion of the myocardium between periods of crossclamping.

This study was undertaken to determine whether intermittent aortic cross-clamping in the fibrillating heart can be used successfully in high-risk coronary artery bypass grafting.

Acute renal dysfunction is a common postoperative complication of CABG. Extracorporeal circulation induces an inflammatory response, causing the release of adhesion molecules by endothelial cells and leukocytes. These adhesion molecules are incriminated in the pathophysiology of renal dysfunction, but their relative importance is unknown. We investigated the relationship between levels of s-ICAM and renal dysfunction following CABG.

Introduction Cardiopulmonary bypass (CPB) has been shown to induce a systemic inflammatory response similar to the local reaction seen after tissue damage [1]. This leads to the release of toxic substances, such as elastase, which cause endothelial damage and may adversely affect outcome [2]. Use of a leucocyte depleting arterial line filter is one of many anti-inflammatory strategies that are undergoing evaluation. Leucocyte depleting filters may be capable of selectively removing activated white cells [3], but this has not been proved in vivo. The aim of the present study was to compare sequential total and activated white cells during CPB, using either a leucocyte depleting or standard arterial line filter. Materials and methods After local ethical committee approval, 20 patients undergoing coronary artery bypass grafting using CPB were prospectively randomly allocated to have either a Leukogard LG–6 (Pall Biomedical, Portsmouth, UK) or a nonleucocyte depleting filter inserted into the arterial line of the CPB circuit. Arterial limb blood samples were taken immediately after institution of CPB (0min) and at 10–min intervals throughout the bypass period. Activated white cells were identified using nitroblue tetrazolium, then both total and activated white cell numbers counted after staining with Leucoplate.Results Table 1 shows the number of white cells counted/1.25 ? l (volume of a single channel of Nageotte counting chamber) using light microscopy (× 25).Conclusion The LG6 leucocyte filter reduces the total white cell count and is capable of selectively removing activated white cells during CPB. The exact relationship between leucocyte depletion and improved patient outcome still remains unclear.