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Background Cardiac surgery remains a significant challenge in patients with coagulation factor VIII (FVIII) deficiency, especially in those with multiple factor deficiencies. Case summary A 79-year-old man with combined FVIII and factor XI (FXI) deficiency was admitted for heart failure treatment. Transthoracic echocardiography revealed aortic stenosis (AS) with decreased left ventricular ejection fraction (LVEF) of 40%, mean aortic pressure gradient of 21 mmHg, and aortic valve area of 0.58 cm2. Coronary angiography revealed significant triple-vessel disease. The patient had multiple comorbidities, including diabetic end-stage renal disease treated with hemodialysis and liver cirrhosis (Child–Pugh score of A). Considering the high surgical risk, a two-stage treatment strategy was developed: the first with off-pump coronary artery bypass grafting (CABG), and the second with transcatheter aortic valve implantation if AS symptoms were significant after CABG. A perioperative hemostatic protocol by the author's heart team was used to appropriately replenish recombinant FVIII concentrates and fresh frozen plasma. The target preoperative and postoperative FVIII coagulation activity values were set at 80–100% and 60–80%, respectively, whereas the target perioperative FXI coagulation activity value was set at 30–45%. Off-pump CABG without aortic manipulation was completed without bleeding events. Transthoracic echocardiography conducted 20 months postoperatively revealed LVEF of 65% and mean aortic pressure gradient of 31 mmHg. The patient leads a normal life 21 months after surgery. Discussion The hemostatic protocol and risk-reduction surgery provided satisfactory surgical results in a patient with significant coronary artery disease and AS, high-surgical-risks, and combined FVIII and FXI deficiency. [ABSTRACT FROM AUTHOR]

Background: Potential long-term gain in health-related quality of life (HRQoL) using off-pump coronary revascularization in elderly patients >70 years has not yet been fully elucidated. Aim: We compared HRQoL in elderly moderate- to high-risk patients 3 months, 12 months, and 8 years after randomization to either off-pump or on-pump coronary artery bypass grafting (CABG). Methods: After randomization and before heart surgery, 120 consecutive patients were asked to fill in the Medical Outcome Study Short Form 36 (SF-36) and Major Depression Inventory diagnostic scale for self-report of HRQoL. Postoperatively, the same questionnaires were mailed to the patients. Results: No significant difference was found in the change of SF-36 scores between the groups except in the social functioning subscale, where the 8-year score was significantly higher for the on-pump group than the off-pump group (p=0.038). In the on-pump group, all scores improved from baseline to 8 years, with the highest improvement in most of the domains after 8 years. In the off-pump group, there was an improvement in four of the eight domains from baseline to 8 years, with the highest improvement in most of the domains after 12 months. By contrast, there was a noticeable decrease in bodily pain, social functioning, and mental health at 8 years after off-pump operation. No patients showed signs of depression after 8 years. Conclusion: HRQoL SF-36 scores seemed to improve more in patients undergoing on-pump CABG compared with patients undergoing off-pump surgery, although no long-term clinically relevant difference between the groups could be demonstrated. [ABSTRACT FROM AUTHOR]

In recent times, practice in cardiac surgery has shifted towards using endoscopic techniques to harvest the saphenous vein from the leg for use as a bypass graft. A paper published in the New England Journal of Medicine (NEJM) in 2009 raised concerns over increased graft occlusion rates in veins harvested endoscopically. This NEJM paper has been criticized, but has nonetheless been influential in guiding practice. We have undertaken this meta-analysis to provide evidence on the clinical outcomes of endoscopic vein harvesting (EVH), so that clinicians can make an informed judgement about whether this technique, popular as it is with patients, should still be offered. We systematically reviewed the global literature and performed a meta-analysis of clinical outcomes after endoscopic and open vein harvesting. In all outcomes, endoscopic harvesting appears to be equal, if not superior, to open harvesting. The suspicion of higher rates of vein graft occlusion was not borne out by randomized studies. When considering evidence from only randomized studies, there is no statistical difference in vein graft stenosis or occlusion between open and endoscopically harvested veins. In conclusion, EVH reduces pain and leg wound complications. At a median follow-up of 2.6 years, we found no significant difference in mortality, myocardial infarction, repeat revascularization, angina recurrence, vein graft stenosis or occlusion. Therefore, the authors support the ongoing use of endoscopic harvesting techniques. [ABSTRACT FROM PUBLISHER]

OBJECTIVE The number of older patients being referred for aortic valve replacement with or without combined coronary bypass grafting (CABG) is increasing. The aim of this study was to evaluate operative risk factors, early and long-term results of isolated aortic valve and aortic valve replacement combined with CABG in octogenarians and nonagenarians. METHODS In the last 10 years, 285 very elderly patients who underwent aortic valve replacement either alone or in combination with coronary artery bypass grafts were retrospectively studied. The population was divided into two groups; isolated aortic valve replacement was performed in 188 patients (group A) and 97 patients had aortic valve replacement combined with coronary surgery (group B). RESULTS The overall hospital mortality was 5.3%, without statistical difference between groups. The incidence of low-output syndrome was higher in group B (P = 0.0001). The multivariate analysis for hospital mortality showed that urgency status, ejection fraction (EF) <35%, intra-operative variables such as clamping time, need for intra aortic balloon pump and post-operative variables such as prolonged ventilation, dialysis, post-operative myocardial infarction and re-thoracotomy for bleeding were independent prognostic factors for hospital mortality. The mean follow-up time was 49.03 ± 19 months. Survival at one, three and five years was 97.1 ± 1.8%, 92.2 ± 2.2% and 82.4 ± 3.6% for group A and 97.2 ± 2.0%, 88.4 ± 2.7% and 75.6 ± 3.2% for group B (P = 0.62), respectively. Age, male gender, post-operative myocardial infarction, urgency status, dialysis, low EF, mean aortic gradient were risk factors for the impaired survival. CONCLUSIONS In our experience, a careful pre-operative evaluation has yielded good surgical results even in older patients with different comorbidities. Associated coronary grafts slightly increase the surgical risk. The role of revascularization on long-term morbidity and mortality is still not clear. It is essential to compare the results of percutaneous and trans-apical aortic valve replacement with the literature results of conventional aortic valve replacement with and without CABG before it can be used as an alternative for very older patients. [ABSTRACT FROM AUTHOR]

Coronary artery bypass surgery is considered as the gold standard treatment of unprotected left main coronary artery (ULMCA) disease. Over the last 20 years, improvement in stent technology and operators experience explained the increased number of reports on the results of percutaneous coronary interventions (PCIs) for the treatment of left main (LM) coronary artery lesion. The recent data comparing efficacy and safety of PCIs using drug-eluting stent and coronary artery bypass surgery showed comparable results in terms of safety and a lower need for repeat revascularization for coronary artery bypass surgery. Patient selection for both techniques is fundamental and directly impacts the clinical outcome. Further randomized trials must be conducted to precise the indications of both techniques of revascularization in the treatment of LM disease. [ABSTRACT FROM PUBLISHER]

Abstract: Background: The axillary artery has been used as an alternate inflow source for revascularization of the lower extremities for four decades. Since 1997, there have been several reports of axillary artery to coronary artery bypass. Methods: All cases of axillary artery to coronary artery bypass at our institution from 1997 through 2003 were reviewed. PubMed was queried for publications on this subject and all pertinent reports were reviewed. Results: Thirty-eight patients underwent axillary artery to coronary artery bypass at our hospital. Most (34) of the operations were performed without cardiopulmonary bypass. Saphenous vein (37) or radial artery (1) grafts were placed to one or more coronary arteries from either the left (36) or right (2) axillary artery. Twenty patients underwent sternotomy, and 18 had either a left (16) or right (2) minimally invasive direct coronary artery bypass (MIDCAB) procedure performed. Most of the sternotomies were for primary myocardial revascularization and most of the MIDCABs were reoperations. There were three deaths—all from non-cardiac causes, one myocardial infarction, and one transient brachial plexus injury. Doppler ultrasound, angiographic, and clinical follow-up were limited, but graft patency has been demonstrated up to 9 years. Conclusion: Axillary artery to coronary artery bypass should be part of the armamentarium of surgeons who perform myocardial revascularization operations. [Copyright &y& Elsevier]

Aims Atrial fibrillation (AF) occurs often in patients after coronary artery bypass grafting (CABG) and can result in increased morbidity and mortality. Previous studies using P-wave signal-averaged electrocardiogram (P-SAECG) have shown that patients with a longer filtered P-wave duration (FPD) have a high risk of AF after CABG. We have shown that patients with an FPD≥124 ms and a root-mean-square voltage of the last 20 ms of the P-wave 20≤3.7 µV have an increased risk of AF after surgery. Accordingly, the aim of this study was to investigate whether or not prophylactic peri-operative administration of amiodarone could reduce the incidence of AF in this high-risk group undergoing CABG identified by P-SAECG. [ABSTRACT FROM PUBLISHER]

Objective: To determine the feasibility and cost of treatment with drug eluting stents in patients with multi-vessel coronary disease referred currently for surgical revascularisation. Methods: Two experienced interventional cardiologists reviewed retrospectively the clinical records and pre-operative coronary angiograms of 209 patients who underwent their first coronary bypass operation for multi-vessel disease without other adjunctive surgical procedures at the Royal Brompton Hospital in 2002. They were classified according to the technical feasibility and completeness of percutaneous revascularisation. A cost decision-analysis model with a cost of drug eluting stents of €2,100 and simulated 1-year costs was constructed. Results: Mean age was 64.6±8.9 years with 54 diabetics (25.8%). Each patient received at least 1 arterial graft and a mean of 3.0±0.8 distal anastomoses. Mean post-operative stay was 8.9±7.2 days and total cost €19,821±1,964. Percutaneous revascularisation was judged to be feasible in 158 (76%) cases. The contraindications were at least 1 unfavourable total occlusion subtending viable myocardium in 48 patients (23%) and extreme tortuosity or calcification in 4 patients (2%). Percutaneous revascularisation of grafted major epicardial vessels was anticipated to be complete in 138 (66%) patients and partial but acceptable in 19 (9.1%) patients. Stenting of the left main, of a ‘favourable’ total occlusion, of bifurcations or in an ostial location would have been required in 32 (20.4%), 60 (38.2%), 77 (49.0%) and 74 (47.1%), respectively, of cases treated. 3.6±1.4 drug eluting stents of total length 72.6±37.3 mm were required to treat 3.3±1.2 lesions per patient at an estimated cost of €17,266±2,850. When one year repeat revascularisation was modelled at a rate of 15% in the stent group there was no significant cost saving from stenting. Conclusions: Although percutaneous revascularisation is feasible in 76% of patients currently undergoing coronary artery bypass grafting for multi-vessel disease, such an approach will involve frequent treatment of complex lesions for which no long term results are available and is unlikely to provide appreciable economic savings. [Copyright &y& Elsevier]

A high frequency (10 MHz) Doppler ultrasound pencil probe was used to estimate flow in coronary artery bypass grafts in vitro and during cardiac surgery. In vitro, increasing the angle of the Doppler transducer in relation to flow caused underestimation of the Doppler derived flow, and using the external rather than internal vessel diameter to calculate cross sectional area caused significant overestimation. This overestimation was considerably greater for the internal mammary artery. Accurate flow estimation was obtained in vitro by the Doppler technique, but considerable variation occurred in patients studied during coronary artery bypass surgery. In conclusion, intraoperative Doppler ultrasound provides a qualitative assessment of phasic flow in coronary artery bypass grafts but is less accurate in quantifying absolute flow in these patients. [ABSTRACT FROM PUBLISHER]

The authors discuss the comparisons made between open vein harvesting (OVH) and endoscopic vein harvesting (EVH) in coronary artery bypass grafting (CABG) surgery. Citing various studies, they state that EVH has an advantage over OVH with respect to postoperative local wound pain and complications. They further comment on the lack of literature for long-term safety of EVH but still render it as a safe and more acceptable option for CABG surgery.