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Purpose: The principal of this analysis was to understand global feature of the number and type of grafts and number of diseased vessels of those undergoing coronary artery bypass grafting (CABG) and their short-term clinical results. Methods and Results: This report presents annual report on the collective data of CABG in the year 2018 (1 January–31 December). Data were collected based on the series of questionnaire which has been performed by The Japanese Association for Coronary Artery Surgery (JACAS), capturing the corresponding data from the Japan Adult Cardiovascular Surgery Database (JCVSD). We also analyzed descriptive clinical results of those undergoing surgeries for acute myocardial infarction and ischemic mitral regurgitation. Conclusion: This is the first article summarizing the results from annually performed questionnaires by JACAS based on JCVSD, on the trend of CABG procedures and clinical results in Japan as a scientific manuscript.

BACKGROUND Total arterial revascularization is associated with increased patency and long-term efficacy and decreased perioperative morbidity and mortality and incidence of cardiac-related events and sternal wound infection compared with conventional coronary artery bypass surgery (CABG), in which the left internal mammary artery (LIMA) is typically grafted to the left anterior descending artery with additional saphenous vein grafts often used. This study determined whether these favorable clinical results could be realized at the authors’ institute. AIM To summarize the early efficacy and clinical experience of individualized total arterial coronary artery bypass grafting surgery. METHODS CABG was performed on 35 patients with non-single-vessel coronary artery disease by adopting total arterial grafts at Fourth Affiliated Hospital of Harbin Medical University between April 2016 and December 2019. LIMA was used in 35 patients, radial artery (RA) was used in 35 patients, and right gastroepiploic artery (RGEA) was used in 9 patients. Perioperative complications were observed, short-term graft patency rate was followed-up, and quality of life was assessed. RESULTS All patients underwent off-pump coronary artery bypass and the surgeries were successful. All of them were discharged without any complications or deaths. During the follow-up, it was found that patients’ angina symptoms were relieved and New York Heart Association classification for cardiac function was class I to class II. A total of 90 vessels were grafted with no occlusion for internal mammary artery, three occlusions for RA, and one occlusion for RGEA. CONCLUSION The individualized total arterial strategy based on the vessels targeting individual anatomic characteristics can achieve complete revascularization with satisfactory short-term grafting patency rate.

Objective: Coronary complications may present during or after repair of congenital heart defects. We report coronary artery bypass grafting (CABG) by internal thoracic artery (ITA) grafts to either coronary artery in children with congenital anomalies. Methods: Four cases who underwent CABG with ITA grafts from March 2016 to March 2020 were retrospectively reviewed. Results: At the time of operation, patient’s ages and weight were 7 and 20 months old and 14 and 15 years old and 6.5, 10, 40, and 45 kg, respectively. Diagnosis were anomalous origin of the left coronary artery from the pulmonary artery with leftward lateral ostial origin (n = 1), neopulmonary annulus hypoplasia post arterial switch with contiguous right coronary artery (RCA) arising from the left facing sinus (n = 1), RCA stenosis after the Ross procedure (n = 1), and right coronary ostial obstruction after aortic valve replacement in truncus arteriosus (n = 1). Procedures included left ITA to left coronary ostium (n = 1), right ventricular outflow tract (RVOT) enlargement with pulmonary valve replacement with left ITA to RCA (n = 1), RVOT enlargement with pulmonary valve replacement with right ITA to RCA (n = 1), and aortic valve re-replacement, pulmonary valve replacement, and right ITA to RCA (n = 1). At last follow-up, all four patients were asymptomatic, with normal ventricular function, and all grafts were patent. Conclusions: The use of CABG in children is valuable alternative when dealing with complex coronary anatomy not suitable for classic repairs. In children, graft patency is required to be longer than 50 years; therefore, use of arterial grafts seems mandatory.

Amaç: Koroner arter cerrahisinde greft açık kalma süresi endotel fonksiyonuna bağlıdır. Nitrik Oksitin (NO) endotel fonksiyonuna yararlı etkisi bilinmektedir. Greftlerdeki Nitrik Oksit düzeyi ve Losartan’ın Nitrik Oksit üzerine etkisi invitro olarak araştırılmıştır. Yöntem: Çalışma 13 hasta da 78 örnek ile yapıldı. İnternaltorasik arter, radial arter ve safenvengreft örnekleri “Kontrol Grubu” ve “Losartan Grubu” olmak üzere ikiye ayrıldı. Losartan grubu örnekleri 1 x 10-5molar Losantanlı Troyde’s solüsyonu çözeltisi içinde inkübe edildi. Nitrik Oksit, Griess yöntemi kullanılarak ölçüldü. İstatistiksel değerlendirme. Kruskal Wallis Oneway ANOVA, İndependentsample T ile Tukey ve Bonferroni testleri kullanılarak yapıldı. Bulgular: Kontrol grubu bazal Nitrik Oksit değeri, internaltorasik arter greftinde anlamlı olarak yüksek bulunmuştur (p

Objective Coronary artery bypass grafting is one of the most commonly performed surgical procedures in cardiovascular surgery with a steadily evolving minimally invasive approach. Methods Conventional coronary artery bypass grafting (CABG) is performed traditionally via midline sternotomy. Exciting advancements in technology and engineering over the last two decades have resulted in the transition from conventional to minimally invasive CABG including robotically assisted surgery. Results The minimally invasive techniques are continuously striving to promote coronary revascularization into the arena of minimally invasive surgery. Examination of 10 previously completed studies with relevant follow-up periods enables an insightful vision into the outcomes and pitfalls surrounding robot-assisted CABG (RACAB) as explored in this review. Studies indicate that RACAB is associated with decreased postoperative complications such as major adverse cardiac or cerebrovascular events without compromise in survival rates. Despite this, certain drawbacks such as incurring costs and technical complexity of the procedure cannot be dismissed. Conclusion There exist patient-related benefits from minimally invasive techniques such as decreased certain postoperative complications. Furthermore, with experience and a specialized stepwise program, it is possible to perform the entire procedure from the console. However, certain pitfalls involving increased expenses, steep learning curve and the lack of proper haptic feedback currently withhold the worldwide expansion of RACAB and limit it to specialized institutions only.

Background Soluble vascular cell adhesion molecule‐1 has been associated with long‐term cardiovascular mortality in patients with stable coronary artery disease and to the development of new atrial fibrillation in subjects with cardiovascular risk factors but no evidence of cardiac disease. Hypothesis Preoperative soluble vascular cell adhesion molecule‐1 predicts the risk of future all‐cause death and cardiovascular death among patients submitted to elective coronary artery bypass surgery. Methods From a cohort of 312 patients who underwent elective coronary artery bypass surgery prospectively followed for a median of 6.7 years, we evaluated the prognostic role of preoperative soluble vascular cell adhesion molecule‐1, inflammatory markers, CHA2DS2‐VASc score and development of postoperative atrial fibrillation (POAF). Univariable and multivariable Cox regression analyses were performed to establish an association of these parameters with long term all‐cause death and cardiovascular death. Results During 2112 person‐years of follow‐up, we observed 41 deaths, 10 were cardiovascular deaths. Independently increased levels of preoperative soluble vascular cell adhesion molecule‐1, POAF, and CHA2DS2‐VASc score were associated with all‐cause mortality. After multivariate adjustment, elevated preoperative soluble vascular cell adhesion molecule‐1 and POAF were the only independent predictors of all‐cause death. Also, preoperative soluble vascular cell adhesion molecule‐1, POAF, and CHA2DS2‐VASc score resulted in being independent predictors of cardiovascular mortality. Conclusions Increased circulating levels of preoperative soluble vascular cell adhesion molecule‐1, together with POAF and CHA2DS2‐VASc score, were significantly associated with future all‐cause death and cardiovascular death among patients submitted to coronary artery bypass surgery.

Objective: To evaluate physiotherapy practices in the rehabilitation of patients undergoing coronary artery bypass grafting. Methods: The cross-sectional study was conducted from October 2016 to January 2017 in cardiac care units of two private and two government hospitals in Karachi, and comprised physiotherapists dealing with patients undergoing coronary artery bypass grafting. Data was collected using a modified and validated version of ‘tucker q’ questionnaire. Data was analysed using SPSS 21. Results: Of the 101 physiotherapists, 60(59.4%) were females and 41(40.6%) were males. The overall work experience was 4.89+2.08 years. Of the total, 60(59.4%) physiotherapists used air suctioning in preoperative physiotherapy practices. Relaxation techniques were used by 86(85.10%) professionals and postural drainage by 85(84.20%), while breathing exercises were used by 65(64.4%) subjects in postoperative physiotherapy practices. Conclusion: Physiotherapists were found to be more or less keeping abreast with advances made regarding managing patients undergoing cardiac artery bypass grafting. Key Words: Coronary artery surgery, Heart surgery, Cardiac rehabilitation, Physical therapy, Breathing exercises, Postoperative care.

Pituitary gland adenoma bleeding is an uncommon complication after coronary artery surgery. Clinical presentation may be variable. We report a case of hemorrhagic complication of a pituitary gland adenoma requiring urgent surgery in a 60-year-old male patient who underwent coronary artery bypass grafting operation.

We read with great interest the recently published study by Wang et al. The authors conducted retrospective study comparing bleeding and transfusion outcomes in patients undergoing coronary artery surgery before and after implementation of Multiplate-guided transfusion algorithm. Put briefly, the introduction of Multiplate-based platelet transfusion algorithm was associated with reduction in transfusion requirements coupled with higher bleeding amount. Study by Wang et al. certainly adds to the current knowledge ; however, some methodological considerations should inevitably be addressed. Multiplate results were correlated to bleeding amount/transfusion requirements. This may pose a great confounding factor here as the Multiplate results were used to guide platelets transfusion. This bias inevitably alters the correlations and provides unreliable Multiplate cutoff points. This methodological flaw may to some degree explain why authors reported different cutoff values relative to those existing in the literature. Another reason for differences in cutoff values may be the anticoagulant used for blood sample collection (i.e., hirudin vs. heparin). From the methodological viewpoint, Multiplate results should not be correlated with transfusion requirements if Multiplate was used to guide transfusion management. When conducting research on the association between platelet function testing and bleeding complications/transfusion requirements, authors should be aware of the entire evidence available so far. It looks like the current evidence pertaining to this research question has not been reviewed systematically. Authors mentioned that most of the available studies are limited by the sample size and retrospective nature of data collection, however, few prospective observational studies using Multiplate in noninterventional research setting have not been mentioned. A thorough insight into available evidence is mandatory to better understand the gaps in knowledge and to appropriately set the research question. When considering the antiplatelet therapy (APT) discontinuation management, we need more precise (i.e., drug specific) information on discontinuation period. Five days of discontinuation period should refer to clopidogrel discontinuation solely (even though there is some evidence suggesting even shorter timeframe to discontinue clopidogrel if coupled with Multiplate ADP test). Widely used ticagrelor should be discontinued 3 days, whereas prasugrel should be discontinued 7 days prior to surgery. Current guidelines suggest Aspirin continuation throughout perioperative period, even though some studies suggest that there may be some proportion of patients with pronounced and prolonged platelet inhibitory response to Aspirin who could possibly benefit from preoperative Aspirin discontinuation. Perioperative platelet dysfunction roots either from (1) preoperative (APT) or (2) intraoperative (cardiopulmonary bypass [CPB]) effect. Clear distinction between these two plausible causes of platelet dysfunction should be made, as it holds great practical value. In present study, preoperative Multiplate testing directed transfusion that is somewhat unreliable as the effect of the CPB on the platelets function remains unknown. For example, the patient with adequate platelet function before surgery will not be transfused even after long CPB time that certainly decreases platelet function. According to our experience, the strongest and the most reliable correlations between Multiplate results and bleeding outcomes/transfusion requirements were noted for the measurements performed after protamine administration, whereas preoperative testing is primarily used for bleeding risk stratification and guiding timing of surgery in context of APT discontinuation. The effect of ADP receptor blockers depends on (1) baseline, inherent platelet ADP receptor activity, (2) platelet inhibitory response to antiplatelet drug, as well as on (3) recovery rate of platelet function after drug discontinuation. Additionally, recovery of platelet function following drug discontinuation could be quantified by serial platelet function testing and once platelet function outgrows predefined cutoff value that delineates bleeding tendency, it would be safe to proceed with surgery regardless the number of days following drug cessation. This personalized approach may shorten waiting time and optimize bleeding and transfusion outcomes at the same time. Authors may simply calculate positive and negative predictive values for the existing cutoff values and in case of preoperative tests, detect who should not be transfused given the sufficient platelet function. We need methodological consensus on the study design and definition of bleeding events. Authors reported the use of UDPB (universal definition of perioperative bleeding) in their study but the results are not presented in context of UDPB?! The study by Wang et al. certainly adds to the current knowledge. Preoperative platelet function testing may be very useful, however, more useful in terms of bleeding risk stratification and possible guiding the timing of surgery in context of recent APT exposure, rather than guiding procoagulant blood components transfusion. Further research in this field is warranted to provide further refinements in hemostatic management.

INTRODUCTION: The effects of midazolam-based intravenous anesthesia (TIVA) and sevoflurane-based inhalation anesthesia (SEVO) maintenance on postoperative hematological parameters were compared in patients undergoing coronary artery surgery. METHODS: The 100 patients included in the study were divided into two groups according to the anesthesia management: All patients' anesthesia inductions were performed with 10 μgkg-1 fentanyl, 0.15 mgkg-1 midazolam, and 0.8 mgkg-1 rocuronium. Anesthesia was maintained with total intravenous anesthesia in the TIVA group patients, while sevoflurane was used in the SEVO group patients. Demographic, clinical, operative data, red cell distribution width (RDW), and mean platelet volume (MPV) values were recorded. RESULTS: Except that the extubation time was shorter in the SEVO group, no difference was observed between the groups in terms of all these variables. There was a significant increase in postoperative RDW and MPV measurements in both groups. Postoperative RDW value was lower in the inhalation anesthesia group compared to the TIVA group (p=0.013). DISCUSSION AND CONCLUSION: In our study, RDW was found to be lower in the inhalation anesthesia group, indicating less inflammation. There was no difference in terms of postoperative complications and mortality.

Aim To assess the preoperative status and the rate of in-hospital complications of coronary artery surgery (CABG) in patients with pre-diabetes compared to patients with type 2 diabetes mellitus (type 2 DM) and normoglycemia. Materials and methods 708 consecutive patients who underwent CABG between 2011 to 2012 were included in the study. All patients without positive history of diabetes underwent an oral glucose tolerance test (OGTT). The lab findings were interpreted in accordance with the recommended diagnostic criteria for diabetes and other glycemic disorders. Results DM screening before coronary artery bypass grafting allowed to diagnose type 2 diabetes in 8.9% (n=63) and prediabetes in 10.4% (n=74) of the study population. The preoperative screening increased the number of patients with DM from 15.2% (n=108) to 24.1% (n=171), and with prediabetes from 3.0% (n=21) to 13.4% (n=95). The total number of patients with carbohydrate metabolism disorders increased from 18.2% (n=129) to 37.5% (n=266). All patients were enrolled into 3 groups based on their glycemic status: Group 1 - without carbohydrate metabolism disorders (n=442), Group 2 - pre-diabetes (n=95), Group 3 - type 2 DM (n=171). The analysis of in-hospital complications reported that patients with pre-diabetes more often underwent urgent peripheral artery bypass compared to the other two groups (p1–2=0.002 vs. p1–3=0.023). The highest rate of wound complications was found in patients with pre-diabetes (p1–2=0.012). In addition, a clear trend towards the rate of other in-hospital complications of CABG in the groups with pre-diabetes and diabetes was found. The regression analysis shows that type 2 DM was associated with the total number of significant complications (odds ratio (OR) 1.731, 95% confidence interval (CI) 1.131–2.626, p=0.012), prolonged in-hospital stay (OR 2.2229, 95% CI 1.412- 3.519, p Conclusion Pre-diabetes affects the in-hospital outcomes after CABG as well as diabetes mellitus. Our findings emphasizes the relevance of active preoperative detection of carbohydrate metabolism disorders. Funding Acknowledgement Type of funding source: None

Introduction The excellent coordination and action by the Ministry of Health of the Nation with the 24 provinces and between the Autonomous City of Buenos Aires and the metropolitan area of the homonymous Province, resulted in the moment, in mortality less than 2% and occupation of critical care beds that does not exceed 63%,.Material and Methods Regarding cardiovascular care in the group of patients over 65 years of age, a more accurate analysis could be performed when two comparative half-yearly periods corresponding to the years 2019 and 2020 (pandemic time) were compared. The data collected regarding this age range revealed issues that had not previously been evaluated in our country. That undoubtedly proposes a different solution for the future based on a strict scientific analysis Results, for example, the number of patients who received a stent in relation to coronary artery surgery is greater than 6 to 1, and compared to surgery without pump and minimally invasive from 69 to 1 Conclusion The Argentinian Perspective is good because has an excellent level of qualified medical training in its cardiac and interventional Cardiologist services, as well as healthcare infrastructure distributed throughout the country, which will undoubtedly be able to respond to the new challenges posed for the post-pandemic stage

The cornerstone of coronary artery bypass surgery undoubtedly remains a perfectly constructed anastomosis, whether it be for graft inflow, such as that between the aorta and a bypass conduit, or for distal perfusion, namely a graft touching down on a target vessel. Multiple studies have demonstrated the long-term efficacy of coronary surgery in alleviating angina syndromes, in enhancing left ventricular function, and, consequently, in improving survival in select patients. Nevertheless, coronary surgeons need to continually strive to do better; the perfect anastomosis is, in and of itself, now no longer enough. With drug-eluting coronary stents and transcatheter therapies rapidly continuing to improve, those patients who require surgery demand more minimally-invasive procedures, through ever-smaller incisions, with more durable grafts, associated with superior long-term patency, and they will not accept the small, but finite risk of stroke that has traditionally been associated with coronary grafting. Anastomotic devices are uniquely suited to fill this niche. They afford the coronary surgeon the opportunity to evolve their technique without compromising on quality. They can eliminate inter and intra-surgeon variability in technical proficiency ensuring rapid construction of reliable, reproducible, and compliant anastomoses, often in difficult-to-access areas, while concomitantly reducing the risk of perioperative neurological injury. The majority of anastomotic devices that have been introduced into the market over the past two decades or so are no longer in use. However, there are still a few that are readily available, with substantial clinical evidence supporting their efficacy.

Purpose The European Society of Cardiology and the European Association for Cardio-Thoracic Surgery as well as the American College of Cardiology and the American Heart association have recognized the “Heart Team” as the best option for a patient centric treatment strategy and has granted a class I recommendation for its formation. The aim of this review is to discuss the evolution, scope and composition, the benefits, and problems inherent in its implementation in the Indian scenario. Methods A review of articles on Heart Team from cardiac surgery as well as multidisciplinary meetings from other specialties was performed. Advantages of Heart Team formation and its implementation have been critically evaluated and its applicability to the Indian scenario considered in particular. Results Heart Team formation is associated with many positives. Concern remains about the implementation of Heart Team approach in its true sense. Heart Team-led decisions are definitely patient centric despite multiple challenges in resource-limited environments. Conclusions Despite the challenges, a multidisciplinary team approach in the form of Heart Team is recommended and its implementation possible in India. However, adjustments to the mechanism of implementation are required. Further research needs to focus on creating models for implementation and assessment of these models in terms of cost effectiveness, improved patient outcomes, and patient satisfaction in the process.

BACKGROUND: The time and conditions may not be suitable for performing polysomnography (PSG) before urgent or emergent surgeries, for example, a coronary artery bypass graft. Unavail-ability in many centers, critical clinical situation, and inability to arrange a timely scheduled appointment are other limitations for PSG. In this study, we aimed to investigate if the STOP-BANG Questionnaire may predict obstructive sleep apnea syndrome (OSAS) related postoperative pulmonary alterations during coronary artery surgery. METHODS: Sixty-one subjects who were scheduled to undergo elective isolated coronary artery bypass graft surgery and were consulted for preoperative pulmonary assessment were recruited to the study. The STOP-BANG Questionnaire was used with the subjects; then their relationship with postoperative complications was assessed. RESULTS: Results of the STOP-BANG Questionnaire revealed that 36.1% of subjects were at high risk for OSAS. Three groups were established according to the STOP-BANG Questionnaire (low risk, group 1; moderate risk, group 2; high risk, group 3) and study parameters, including PEEP value in ventilator, detection of apnea at ventilator, CPAP time after extubation, SpO2 1 h after extubation, postoperative hypoxemia, need for CPAP, and ICU length of stay revealed significant relationships among these groups. CONCLUSIONS: The STOP-BANG Questionnaire may predict the OSAS risk and OSAS-related pulmonary complications for patients who are candidates for a coronary artery bypass graft and unable to be evaluated with PSG before surgery due to technical or time-related limitations. © 2018 Daedalus Enterprises.

Background: Patients with increased glycated hemoglobin (HbA1c) seem to be at increased risk of sternal wound infection (SWI) after coronary artery bypass grafting (CABG). However, it is unclear whether increased baseline HbA1c levels may affect other postoperative outcomes. Material and methods: Data on preoperative levels of HbA1c were collected from 2606 patients undergoing elective isolated CABG from 2015 to 2016 and included in the prospective, multicenter E-CABG registry. Results: The prevalence of HbA1c ≥ 53 mmol/mol (7.0%) among non-diabetics was 5.3%, among non-insulin dependent diabetics was 53.5% and among insulin dependent diabetics was 67.1% (p < 0.001). The prevalence of HbA1c > 75 mmol/mol (9.0%) among non-diabetics was 0.5%, among non-insulin dependent diabetics was 5.8% and among insulin dependent diabetics was 10.6% (p < 0.001). Baseline levels of HbA1c ≥ 53 mmol/mol (7.0%) was a significant predictor of any SWI (10.7% vs. 3.3%, adjusted p-value

Most recent studies tend to confirm the beneficial effect of thoracic epidural analgesia (TEA) in cardiac surgery.To assess whether intensive care unit TEA has an influence on the perioperative course following low-risk coronary artery surgery.This prospective, randomized trial was performed in patients scheduled for low-risk coronary artery surgery. Eighty patients undergoing off-pump or on-pump coronary artery bypass surgery were prospectively randomized to receive either combined general and epidural anesthesia or general anesthesia only. Time of postoperative ventilations and intensive care unit stay was compared between the groups. For all comparisons (The addition of TEA to general anesthesia significantly attenuated the stress response expressed by intraoperative heart rate, systolic blood pressure and cumulative doses of opioids. Time to the return of spontaneous respiration, time to extubation and time of stay in the postoperative care unit were all shorter in the study group, with no difference in hospital stay. Patients with TEA required midazolam less frequently (12.8% vs. 53.8%,Addition of TEA to general anesthesia shortens the return of respiratory function, duration of mechanical ventilation and ICU stay in the postoperative period after coronary artery surgery, providing comparable hemodynamic stability to general anesthesia alone.Ostatnie badania potwierdzają korzystny efekt zastosowania piersiowej blokady zewnątrzoponowej w kardiochirurgii.Ocena, czy piersiowa blokada zewnątrzoponowa wpływa na przebieg okresu pooperacyjnego u chorych z grupy niskiego ryzyka poddawanych operacjom pomostowania naczyń wieńcowych.Prospektywne badanie z randomizacją przeprowadzono u chorych z niskim ryzykiem zakwalifikowanych do operacji rewaskularyzacji naczyń wieńcowych. Osiemdziesięciu pacjentów zakwalifikowanych do operacji pomostowania tętnic wieńcowych w krążeniu pozaustrojowym lub bez użycia krążenia pozaustrojowego włączono do złożonego znieczulenia ogólnego i zewnątrzoponowego lub znieczulenia ogólnego. W analizowanych grupach porównano czas pooperacyjnej wentylacji i pobytu chorych na oddziale intensywnej terapii. Dla wszystkich przeprowadzonych obliczeń wartość współczynnikaUzupełnienie znieczulenia ogólnego o blokadę zewnątrzoponową istotnie zredukowało odpowiedź stresową wyrażoną przez śródoperacyjną częstość akcji serca, skurczowe ciśnienie tętnicze i skumulowane dawki opioidów. Czasy powrotu oddechu własnego, pooperacyjnej wentylacji oraz pobytu na oddziale pooperacyjnym były istotnie krótsze w grupie badanej, nie było różnicy w czasie hospitalizacji. Pacjenci, u których zastosowano blokadę zewnątrzoponową, rzadziej wymagali zastosowania midazolamu (12,8% vs 53,8%,Uzupełnienie znieczulenia ogólnego o blokadę zewnątrzoponową skraca powrót prawidłowej funkcji układu oddechowego, czas trwania wentylacji mechanicznej i czas pobytu na oddziale intensywnej terapii po operacji tętnic wieńcowych, zapewniając porównywalną stabilność hemodynamiczną.

Background Surgical skill assessment tools frequently reflect the opinions of small groups of surgeons. That raises concerns over their generalizability as well as their utilization when applied broadly. A Delphi approach could engage a broad group of experts to identify key elements for a checklist assessing coronary anastomotic skill, improving generalizability. Methods Expert surgeons in North America (10 or more years in practice, actively teaching coronary artery surgery) were contacted randomly to participate. Consenting surgeons first provided items they believed were mandatory when performing a coronary artery bypass. These were then entered into a three-round Delphi. Positive consensus was reached when 75% or more of participants ranked an item mandatory. Results Sixteen faculty consented to participate. Each participant provided 25 ± 10 items. The 407 items provided were condensed, resulting in 146 items in the final list, divided into six sections based on the conduct of the operation. Twenty-three items reached consensus in the first round, 14 in the second, and 3 in the third. These 40 items represented only 27% of the initial 146 items. Agreement within sections varied widely, from 0% for "management of assistants" to 47% for "testing and final steps." Conclusions A randomly selected group of experts using a Delphi approach can generate a checklist to assess construction of a coronary artery bypass. Considerable disagreement among experts regarding what steps are mandatory calls into question the generalizability of any locally developed checklist.

BackgroundWe sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta‐analytic approach limited to randomized controlled trials and propensity‐matched studies for clinical outcomes, in which graft patency was analyzed.MethodsA systematic literature review was conducted using PubMed and MEDLINE to identify publications containing comparisons between endoscopic radial artery harvesting (ERAH) and open harvesting (ORAH). Only randomized controlled trials and propensity‐matched series were included. Data were extracted and analyzed with RevMan. The primary endpoint was wound complication rate, while secondary endpoints were patency rate, early mortality, and long‐term cardiac mortality.ResultsSix studies comprising 743 patients were included in the meta‐analysis. Of them 324 (43.6%) underwent ERAH and 419 (56.4%) ORAH. ERAH was associated with a lower incidence of wound complications (odds ratio: 0.33, confidence interval 0.14‐0.77; p = 0.01). There were no differences in graft patency, and early and long‐term cardiac mortality between the two techniques.ConclusionERAH reduces wound complications and does not affect graft patency, or short‐ and long‐term mortality compared to ORAH.

We describe a surgical technique for late recruitment of the proximally occluded left main coronary artery (LMCA) after initial arterial switch operation, which had been complicated by severe left ventricular dysfunction. This technique allowed for LMCA recanalization, using the patent conal artery branching off the LMCA close to the ostium. It is particularly useful in small children, where surgical options for coronary arteries are limited and associated with a high risk of restenosis. It was successfully used in a two-month-old boy with successful revascularization confirmed by angiography.

Введение. Синдром низкого сердечного выброса основное и наиболее опасное осложнение коронарного шунтирования (КШ) у больных с низкой фракцией выброса левого желудочка (ФВЛЖ), повышающее госпитальную летальность. Снизить риск его развития главная задача предоперационной медикаментозной подготовки. Помимо стандартных препаратов для лечения сердечной недостаточности (СН) с этой целью используется левосимендан, способный сохранять кислородный баланс ишемизированного миокарда на фоне положительного инотропного действия. Получены обнадеживающие результаты сохраняется потребность в накоплении данных. Материал и методы. Обследованы 59 пациентов с многососудистой коронарной болезнью и ФВЛЖ35, которым выполнено КШ. Из них 19 пациентов, оперированных в 20162017 гг., за 23 сут до операции в дополнение к стандартной терапии хронической СН получили предоперационную подготовку левосименданом (12,5 мг в течение 2410,5 ч, без болюса) и составили группу Л. Группу ретроспективного контроля К сформировали 40 пациентов, оперированных ранее, которые получали только стандартную терапию ХСН. Проведено сравнение госпитальных результатов КШ у больных обеих групп. Результаты. При сходной длительности искусственного кровообращения проблемы при его отключении развивались в группе Л реже (5 против 20), однако статистическая достоверность не достигнута по причине различной численности групп. Также отмечена тенденция к меньшей продолжительности послеоперационной инотропной поддержки (24 ч против 72 ч) у больных, получивших левосимендан использовались более низкие дозы препаратов. Заключение. При включении левосимендана в предоперационную подготовку больных с ишемической болезнью сердца с низкой ФВЛЖ определенно прослеживается позитивный эффект на течение постперфузионного и раннего послеоперационного периодов. Исследование рассматривается как пилотное. На основании полученных данных принято решение о продолжении изучения эффективности препарата в аналогичной селективной группе больных с целью формировании весомой доказательной базы.Objective. Low cardiac output syndrome is the main complication of coronary artery bypass surgery (CABG) in patients with low left ventricular ejection fraction (LVEF), wich increases in-hospital mortality. To reduce the risk of this syndrome is the main goal of preoperative medical preparation. Levosimendan (L) in addition to standard therapy for chronic heart failure (CHF) is expected to be useful for this purpose due to its ability to maintain oxygen balance in ischemic myocardium and at the same time showing a positive inotropic action. Promising results have already received there is still a need to accumulate more data. Methods. 59 patients with multivessel coronary disease and LVEF 35 who underwent CABG were included. 19 patients received L, administered by a cardiologist, as infusion of 12.5mg for 24 10,5h, without a bolus, 2 days before surgery (group L). 40 patients, operated earlier, made up the retrospective control group (group C). We compared in-hospital results of CABG in patients with LVEF35 who was preoperatively treated only with standard therapy for CHF (group C) and who additionally received levosimendan (group L). Results. While the duration of cardiopulmonary bypass was similar, the problems after weaning developed significantly less frequently in group L (5 vs 20), however, statistical significance was not achieved due to the different size of the groups. We also noted a tendency for a shorter duration of postoperative inotropic support (24h vs 72h) in patients who received L as well as significantly lower doses of sympathomimetics used. Conclusion. The inclusion of levosimendan in the preoperative preparation of CAD patients with low LVEF definitely has a positive effect on the CABG results and the course of the early postoperative period. The study is considered as a pilot. It is necessary to continue to form a significant evidence base and to confirm the cardioprotective effect of levosimendan in a similar selective group of patients.

Amaç: Otolog Vena Saphena Magna (VSM) koroner arter cerrahisinde kullanılan en yaygın baypas materyalidir. Genellikle Vena Saphena Magna standart uzun medial bacak insizyonu ile hazırlanmakta olup; insizyon hattında iyileşme problemleri sıklıkla izlenmektedir. Bu çalışmada, otolog VSM çıkarılmasında endoskopik yöntem, klasik ve tünel yöntemlerinin karşılaştırması yapılmıştır. Gereç ve Yöntem: Koroner baypas ameliyatı olan 40 hasta randomize ve retrospektif olarak seçildi. 10 hastada endoskopik yöntem ile, 15 hastada tünel ve 15 hastada klasik yöntem ile VSM çıkarılmıştır. Çalışmada bacak insizyonu ile ilgili olarak postop hastanede kalış süresi, kullanılan antibiyoterapi, ek antibiyotik ihtiyacı, üst bacak çapı, sızıntı, hematom, açık yara bakım süresi, kültür antibiyogram, insizyon boyutu, komplikasyon yeri, maliyet, postoperatif şikayet, ortalama VSM çıkarma süresi, VSM uzunluğu, kapalı pansuman günü, elastik bandaj süresi, drenaj miktarı, postoperatif ağrı skorlaması karşılaştırılmıştır. Bulgular: Tünel ve endoskopik yöntem grubunda çalışma sonunda klasik gruba göre, insizyon uzunluğunda, postoperatif ağrıda, major komplikasyon gelişiminde, insizyonu kapama süresinde, insizyonu kapamada kullanılan sütür materyalinde azalma saptanmıştır. Bunun yanında mükemmel bir kozmetik sonuçla hasta memnuniyeti artmış, erken dönemde mobilizasyonda rahatlık sağlanmıştır. Sonuç: Klasik yönteme göre endoskopik teknik ve tünel yöntemi uygulanan hastalarda bacaktaki insizyon sorunlarının daha az görüldüğü ve hastanede kalış süresinin, kullanılan sütür materyali miktarı ve insizyonu kapama süresinin, insizyon uzunluğunun ve postoperatif ağrının daha az olduğu gözlenmiştir. Hastanın mobilize olma süresinin de kısaldığı saptanmıştır. Bu sonuçlara göre endoskopik ve tünel yöntemlerinin kullanımının klasik yönteme üstünlüğü göz önünde bulundurulmalıdır., Objective: Autologous vena saphena magna is the most common bypass material used in coronary artery surgery. It is generally prepared with a long medial leg incision, and so healing problems are often observed. In this study, we aimed to compare endoscopic, classical and tunnel techniques in saphen harvesting. Material and Method: Fourty patients, who were selected randomly and retrospectively, were included in the study. Endoscopic saphen harvesting was performed on 10 patients, the tunnel technique was performed on 15 patients and the classical method was performed on 15 patients. Postoperative hospital stay, antibiotics, additional antibiotic requirement, upper leg size, hematoma, open care time, culture antibiogram, incision size, complication site, cost, postoperative complaints, median vena saphena magna harvesting time, vena saphena magna length, closed dressing time, elastic bandage time, drenaige amount, postoperative pain scores (Visual Analogue Scale-VAS) were all factors compared regarding saphen insicion site. Results: In tunnel end endoscopic procedures; insicion length, postoperative pain, major complication rate, incision closure time, the sutur material reqired for closing incisions were lower than the classical technique group. Moreover, the level of patients’ satisfaction was increased due to perfect cosmetic results and ease of early mobilization. Conclusion: Comparing classical saphen harvesting techniques with endoscopic and tunnel methods, it was found that incision problems, length of hospital stay, sutur material amounts, incision closure time, incision length and postoperative pain were detected in lower numbers in endoscopic and tunnel methods. Depending on these factors, the patient’s mobilization time was shortened. According to these results, the superiority of the endoscopic and tunnel methods compared to the classical method should be considered.

Objectives To assess the reliability of EuroSCORE II in an entire population after isolated coronary artery surgery and separately among patients who underwent redo surgery due to bleeding, and to create a model predicting hospital death among patients who underwent redo surgery owing to bleeding. Design Retrospective study based on data from the Polish National Registry of Cardiac Surgical Procedures. Setting Multi-institutional study. Participants The study comprised 41,353 patients who underwent isolated coronary artery surgery in Poland between January 2012 and December 2014. Interventions None. Measurements and Main Results EuroSCORE II reliability was estimated using the area under the receiver operating characteristics curve (AUC), the observed-to-expected surgical mortality ratio (O/E), and the Hosmer-Lemeshow test. Parameters of the function correcting the original EuroSCORE II were determined using the least squares method. The original score was adjusted using a created formula. Among the 41,353 patients, 1,406 (3.4%) underwent reexploration. Even though EuroSCORE II was reliable in predicting hospital mortality in the entire population (AUC 0.76, O/E ratio 1.08), it greatly underestimated mortality for patients who required reexploration (AUC 0.74, O/E ratio 4.33). In this subpopulation, the worst performance of the EuroSCORE II was noted among patients with the lowest predicted mortality (0.50%-0.82%) Accurate calibration was obtained by adding a coefficient and creating a nomogram. Conclusions EuroSCORE II was reliable in a Polish population undergoing isolated coronary surgery. After redo surgery for bleeding, the observed mortality was much higher than in the overall coronary population, but the rate was made more accurate by adding a coefficient to the initially calculated EuroSCORE II.

Background: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is rare. Unique anatomical characteristics observed include tethering secondary to the extensive collateral vessels, severe native coronary tortuosity, and massive dilation of the coronary arteries. This requires specific technical consideration to ensure safe translocation. Methods: A single-center retrospective review of six patients with ARCAPA was performed. Echocardiographic and computerized tomography scan data were analyzed for anatomical and functional cardiac characteristics. Operative techniques were analyzed, which reflected an evolution toward a modified-trapdoor technique. Results: Five children presented with asymptomatic murmurs and one adult patient with unstable angina. All patients underwent successful surgical correction. The modified trapdoor technique provided the most ideal geometry for coronary transfer secondary to its anatomical characteristics. Two patients had coronary button transfers above the sinotubular junction using vertical stab incisions, one had the button implanted after excising part of the aortic wall, and last three patients had modified trapdoor incisions. Mean cardiopulmonary bypass and cross-clamp times were 170 ± 27 minutes and 99.5 ± 29 minutes respectively. The average hospital stay was five days and there were no mortalities. Conclusions: Anomalous right coronary from the pulmonary artery’s unique anatomical characteristics require a coronary transfer technique different from that performed in aortic root replacement. In some respects, our modified technique resembles coronary transfers used in difficult arterial switch operations. The use of a modified trapdoor incision simplifies coronary transfer and may minimize coronary kinking and subsequent complications related to coronary transfer.

OBJECTIVES Surgical re-exploration due to postoperative bleeding that follows coronary artery surgery is associated with significant morbidity and mortality. The aim of this study was to assess a relationship between re-exploration, major postoperative complications, in-hospital mortality and mid-term outcomes in patients following coronary surgery, on the basis of nationwide registry data. METHODS We identified all consecutive patients enrolled in Polish National Registry of Cardiac Surgical Procedures (KROK Registry) who underwent isolated coronary surgery between January 2012 and December 2014. Preoperative data, major postoperative complications, hospital mortality and mid-term all-cause mortality were, respectively, analysed. Comparisons were performed in all patients, low-risk patients (EuroSCORE II RESULTS Among 41 353 analysed patients, 1406 (3.4%) underwent re-exploration. Reoperated patients had more comorbidities, more frequent major postoperative complications, higher in-hospital mortality (13.2% vs 1.8%, P CONCLUSIONS Surgical re-exploration due to postoperative bleeding following coronary artery surgery carries a high risk of perioperative mortality and is linked to major postoperative complications. Among patients who survive to hospital discharge, mid-term mortality is associated primarily with preoperative comorbidities.

We describe the heart from a 79-year-old woman with no medical history of cardiac complaints. Her heart shows a regular right coronary artery (RCA) and a variant left coronary artery (LCA) arising from the right sinus of Valsalva. The common stem of the RCA and the LCA is extremely short. The LCA depicts a preinfundibular course with a cranial-anterior loop and reaches the intersection of the anterior interventricular sulcus and the left coronary sulcus, where it divides into the regular branches, the anterior interventricular branch (left anterior descending, LAD) and the circumflex branch (left circumflex, LCx). All further branching resembles a normal distribution with the posterior interventricular branch coming for the RCA. Such a variant LCA is extremely rare with a reported incidence of 0.17 %. However, recognition and angiographic demonstration of such a variation assume the highest priority in a patient undergoing, for instance, direct coronary artery surgery or prosthetic valve replacement.

Background: The aim was to determine the association between atrial fibrillation (AF) and outcome in patients undergoing coronary artery bypass grafting (CABG). Methods: All patients undergoing CABG between January 2010 and June 2013 were identified in the Swedish Heart Surgery Registry. Outcomes studied were all-cause mortality, cardiovascular mortality, myocardial infarction, congestive heart failure, ischemic stroke, and recurrent AF. Patients with history of AF prior to surgery (preoperative AF) and patients without history of AF but with AF episodes post-surgery (postoperative AF) were compared to patients with no AF using adjusted Cox regression models. Results: Among 9,107 identified patients, 8.1% (n = 737) had preoperative AF, and 25.1% (n = 2,290) had postoperative AF. Median follow-up was 2.2 years. Compared to no AF, preoperative AF was associated with higher risk of all-cause mortality, adjusted hazard ratio with 95% confidence interval (HR) 1.76 (1.33–2.33); cardiovascular mortality, HR 2.43 (1.68–3.50); and congestive heart failure, HR 2.21 (1.72–2.84). Postoperative AF was associated with risk of all-cause mortality, HR 1.27 (1.01–1.60); cardiovascular mortality, HR 1.52 (1.10–2.11); congestive heart failure, HR 1.47 (1.18–1.83); and recurrent AF, HR 4.38 (2.46–7.78). No significant association was observed between pre- or postoperative AF and risk for myocardial infarction and ischemic stroke. Conclusions: Approximately 1 in 3 patients undergoing CABG had pre- or postoperative AF. Patients with pre- or postoperative AF were at higher risk of all-cause mortality, cardiovascular mortality, and congestive heart failure, but not of myocardial infarction or ischemic stroke. Postoperative AF was associated with higher risk of recurrent AF.

Optimal timing to discontinue ticagrelor before cardiac surgery: do we need additional evidence?

Congenital obstruction of the left main coronary artery is a complicating feature of supravalvular aortic stenosis. We describe an eight-month-old female patient with Williams syndrome, supravalvular aortic stenosis, and branch pulmonary artery stenosis, with concomitant anomaly of severe obstruction of the left coronary artery orifice.

Objective: Recent conflicting studies on the renal effects of N-acetyl cysteine (NAC) after cardiac surgery have been published. The aim of this study was to evaluate the renal effects of NAC using neutrophil gelatinase-associated lipocalin (NGAL) blood levels in elderly patients undergoing coronary artery bypass grafting (CABG). Methods: This randomized, double-blinded, placebo-controlled study was conducted among geriatric patients (>65 years) scheduled to undergo CABG. A total of 60 consecutive patients were randomly assigned to 2 groups. The first group received I.V. NAC (n=30) and the second group received placebo (n=30) at induction of anesthesia and then for 20 h. NGAL values were determined and conventional renal function tests were performed. Statistical analysis was performed using SPSS 17.0 (IL, Chicago, USA). A p value of 25% of the baseline value at any time during the study period were observed in 27% of patients in the NAC group and 37% of patients in the placebo group; the difference was statistically significant (p

Background: The complexity of coronary artery disease is usually a neglected factor in risk stratification systems. We aimed to analyze the discriminative ability of the clinical SYNTAX score (CSS) for acute kidney injury (AKI) following on- and off-pump coronary artery surgery. Methods: A total of 193 patients were reviewed in this study. Patients were divided into two groups according to the surgical procedure (group I: off-pump coronary artery bypass grafting, n = 89; group II: on-pump coronary artery bypass grafting, n = 104). Preoperative demographic data, the CSS and postoperative renal functions were evaluated. The postoperative AKI classification was made using the RIFLE (Risk, Injury, Failure, Loss of function, and End-stage renal disease) criteria. Results: Postoperative AKI occurred in 14 of 89 patients (15.7%) in group I and in 29 of 104 patients in group II (27.8%; p = 0.046). The CSS did not vary much between the groups (31.52 ± 13.08 vs. 29.89 ± 15.70; p = 0.638). In group I, the CSS was not different between patients with AKI and those without AKI (30.167 ± 3.93 vs. 31.91± 14.75; p = 0.78). In group II, the CSS was 36.85 ± 18.33 in patients with AKI and 28.02 ± 12.32 in those without, and the difference was significant (p = 0.02). The discriminative ability of the CSS for postoperative AKI using the AUC analysis was 0.500 in group I and 0.840 in group II. Conclusion: The CSS may be a simple and successful means of risk prediction of postoperative AKI in on-pump coronary artery surgery.

Objectives: To compare the effects of different routes and timings of administration of dopamine and mannitol used to alleviate the adverse effects of prolonged cardiopulmonary bypass (CPB) on renal functions in coronary artery surgery. Methods: Group I (n: 25 patients): Mannitol 1 g/kg was added into the priming solution for CPB. Group II (n: 25 patients): IV dopamine was administered at a dose of 2 μg/kg/min during the time period between anesthesia induction and end of surgery. Group III (n: 25 patients): IV dopamine was administered at a dose of 2 μg/kg/min during the time period between anesthesia induction and end of surgery and mannitol 1 g/kg was added into the priming solution for CPB. Group IV (n: 25 patients) (Controls): Furosemide was given when the urine output was low. Results: There was a significant increase in post operative urine microalbumin/creatinine ratio in all groups (p < 0.05), even increase of cystatin-c in Groups I, II and III (p < 0.01). Conclusions: We believe that concurrent use of dopamine infusion (2 μg/kg/min) with mannitol (1 g/kg) during CPB may represent a more effective strategy for the prevention of the untoward effects of CPB on renal functions.