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OBJECTIVES: The aim of the study was to determine if there is a long-term outcomes disadvantage associated with using the internal mammary artery (IMA) as a free graft to the left anterior descending artery (LAD) during coronary artery bypass graft surgery. METHODS: Between 1991 and 2014, 21 876 consecutive patients underwent isolated primary coronary artery bypass graft surgery at our institution. Among these, 238 underwent a free IMA (f-IMA) graft to bypass the LAD. Propensity score matching with bootstrap analysis was performed to produce a cohort of 222 f-IMA patients matched to 222 patients with in situ IMA grafting to the LAD. Early and long-term outcomes including survival, readmission for cardiovascular causes and repeat revascularization up to a maximum of 23 years post-coronary artery bypass graft surgery were compared. Provincial vital statistics and administrative hospital readmission data were used to analyse long-term outcomes. RESULTS: Operative mortality [3.2% f-IMA vs 1.9% in situ IMA; odds ratio = 1.79, 95% confidence interval (CI) = 0.91-3.52] and the majority of postoperative adverse events were not significantly different among matched patients. The risk of late death was not significantly different between the 2 matched groups (hazard ratio = 1.14, 95% CI = 0.92-1.41, P = 0.15). The risk of hospital readmission for cardiovascular reasons was significantly higher in the f-IMA group (54.5% vs 47.3%, odds ratio = 1.4; 95% CI = 1.10-1.72), although repeat revascularization (18.4% vs 13.5%; odds ratio = 1.53, 95% CI = 0.96-2.44) was not significantly different between the matched groups. CONCLUSIONS: Late survival and the need for repeat coronary revascularization were not influenced by using the IMA as a free graft to the LAD. However, there is a small but significant increase in the risk of hospital readmission for cardiac reasons. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. Methods: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n =60) and fibroelastic deficiency (FED) (normal leaflets, n =64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p <0.001). The clinical profile was different: age (60±14 vs 73±8 years, p <0.001), systemic hypertension (22% vs 70%, p <0.001), chronic renal insufficiency (5% vs 22%, p <0.01), cancer (7% vs 25%, p <0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p <0.001), aortic atheroma (21% vs 51%, p <0.001) and coronary disease (22% vs 56%, p <0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49mm), left ventricular end-diastolic diameter (62 vs 54mm), interventricular septal thickness (11 vs 13mm), and systolic pulmonary pressure (40 vs 56mmHg), respectively (p <0.001). Bacterial endocarditis was observed in 24 cases (19%). Results: The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p <0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p <0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p <0.01). The mean follow-up was 50±41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p <0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p <0.001). Five-year survival was higher following repair than replacement (84% vs 64% p <0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p <0.01). Conclusions: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome. [Copyright &y& Elsevier]

Abstract: Aortic valve replacement (AVR) in patients who have undergone previous coronary artery bypass grafting (CABG) is a challenging redo surgery. We undertook this study to evaluate the early and late outcomes of patients operated upon using a simplified surgical approach. Between January 2001 and December 2005, 2238 patients underwent AVR in our institution. We reviewed retrospectively the 57 patients who had AVR following previous CABG. All patients underwent cardiopulmonary bypass with a mild-to-moderate systemic hypothermia (mean temperature: 29.7±2.5°C). Patent internal thoracic artery (IMA) grafts were never dissected, controlled or clamped. A mechanical or biological prosthesis was implanted considering the patient''s age. The mean cardiopulmonary bypass (CPB) time was 93±29min (median: 80min, range: 43–244min) and the mean aortic cross-clamp (AoX) time was 63±18min (median: 59min, range: 31–125min). The early mortality was 10.5% and the late mortality was 9.8% (mean follow-up time: 38 months). The survival was 81% at 5 years and the freedom from major cardiac events was 77%. In conclusion, from our experience, the operating quickness and a simplified approach (‘open IMA technique’, anterograde cardioplegia, mild-to-moderate hypothermia and minimal dissection of the mediastinal structures) represent two fundamental choices to perform this type of surgery easily, safely and with optimal results. [Copyright &y& Elsevier]

Abstract: We would like to report a rare case of post-stenotic aneurysm of the pulmonary trunk and its left branch in a 51-year-old man. His cardiac disease, which was first diagnosed at the age of 4, was left untreated because of absence of symptoms and normal physical development. A CT scan, recently performed because of decrease in exercise tolerance and worsening dyspnea, showed a pulmonary artery aneurysm (52mm×79mm). The echocardiography revealed a severe pulmonary commissural stenosis. Through a surgical approach the pulmonary trunk and its left branch were excised and reconstructed using a 30mm Dacron graft; the right pulmonary branch was then reimplanted on the right side of the tube. The patient''s postoperative course was uneventful. He was discharged on the seventh postoperative day and there were no adverse events or complications at 1- and 3-month follow-up. [Copyright &y& Elsevier]