Search

Coronary artery bypass grafting surgery effectively relieves signs and symptoms of myocardial ischemia. The left internal thoracic artery (LITA) graft is the gold standard having 90-95% patency rate at 10 years, whereas only 50% of saphenous vein (SV) grafts are patent at 10 years. However, there is a novel "no touch" technique in order to harvest an SV complete with its cushion of surrounding tissue, thus maintaining its endothelium-intact. Significantly superior short- and long-term graft patency rates comparable to LITA grafts can be achieved. Consequently, the SV may be revived as an important conduit in coronary artery bypass surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether combined surgical procedures in one or two stages are the best surgical treatment strategy in patients with simultaneous coronary artery disease and lung cancer. Altogether, 264 papers were found using the reported search; of which, 15 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The outcomes of the reported studies provided interesting results. All the studies were retrospective. Ten papers reported the results of combined and staged operations. The operative mortality rate of combined procedures was 0-20.8% and of staged procedures was 0-10%. The reoperation rate for bleeding of combined procedures was 0-11% and of staged procedures was 0%. The survival rate of combined procedures at 1 year was 79-100%, at 5 years was 34.9-85% and at 7 years was 61%. The survival rate of staged procedures at 1 year was 72.7% and at 5 years was 53%. Five studies reported the results of off-pump coronary artery bypass grafting (OPCABG) and lung surgery versus on-pump and lung surgery. The operative mortality rate of OPCABG and lung surgery was 0-6.6%. The 2-year survival rate of OPCABG and lung surgery was 47% and the 5-year survival rate was 13-68%. The re-exploration rate for bleeding of OPCABG was 4%. Simultaneous lung surgery and CABG could be safely performed with adequate cancer-free survival in patients with Stage I or II lung cancer. Lung surgery is better performed before institution of cardiopulmonary bypass, avoiding the complications of such a technique. Long-term survival after combined treatment is mostly related to the predicted survival after lung resection. This depends on the T stage and mostly on the patient's nodal status. In certain high-risk groups (if the cardiac procedure is difficult or if the patient is unstable), separate staged procedures (CABG as the first and lung resection as the second procedure) might be the most prudent action (3-6 weeks apart). There is also another option: OPCABG and lung resection, which could be a safe and effective treatment when unstable coronary heart disease and lung cancer coexist., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Radial artery (RA) is the most popular arterial graft after the left internal thoracic artery in both low- and high-risk patients undergoing coronary artery bypass grafting. Various arterial grafts such as the right internal thoracic artery, the right gastroepiploic artery, and the inferior epigastric artery have also gained ground over the past 30 years because of the intimal hyperplasia and atherosclerosis of the saphenous vein leading to late graft occlusion. In this review article we would like to present the utility of the RA as a graft, focused mainly on its structural and biological characteristics., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Atrial fibrillation (AF) occurs in 28-33% of the patients undergoing coronary artery revascularization (CABG). This study focuses on both pre- and peri-operative factors that may affect the occurrence of AF. The aim is to identify those patients at higher risk to develop AF after CABG., Patients and Methods: Two patient cohorts undergoing CABG were retrospectively studied. The first group (group A) consisted of 157 patients presenting AF after elective CABG. The second group (group B) consisted of 191 patients without AF postoperatively., Results: Preoperative factors presenting significant correlation with the incidence of post-operative AF included: 1) age > 65 years (p = 0.029), 2) history of AF (p = 0.022), 3) chronic obstructive pulmonary disease (p = 0.008), 4) left ventricular dysfunction with ejection fraction < 40% (p = 0.015) and 5) proximal lesion of the right coronary artery (p = 0.023). The intraoperative factors that appeared to have significant correlation with the occurrence of postoperative AF were: 1) CPB-time > 120 minutes (p = 0.011), 2) myocardial ischemia index < 0.27 ml.m2/Kg.min (p = 0.011), 3) total positive fluid-balance during ICU-stay (p < 0.001), 4) FiO2/PO2 > 0, 4 after extubation and during the ICU-stay (p = 0.021), 5) inotropic support with doses 15-30 μg/Kg/min (p = 0.016), 6) long ICU-stay recovery for any reason (p < 0.001) and perioperative myocardial infarction (p < 0.001)., Conclusions: Our results suggest that the incidence of post-CABG atrial fibrillation can be predicted by specific preoperative and intraoperative measures. The intraoperative myocardial ischemia can be sufficiently quantified by the myocardial ischemia index. For those patients at risk we would suggest an early postoperative precautionary anti-arrhythmic treatment.

Preoperative medication by inhibitors of angiotensin-converting enzyme (ACE) in coronary artery patients predisposes to vasoplegic shock early after coronary artery bypass grafting. Although in the majority of the cases this shock is mild, in some of them it appears as a situation, "intractable" to high-catecholamine dose medication. In this study we examined the possible role of prophylactic infusion of low-dose vasopressin, during and for the four hours post-bypass after cardiopulmonary bypass, in an effort to prevent this syndrome. In addition, we studied the influence of infused vasopressin on the hemodynamics of the patients, as well as on the postoperative urine-output and blood-loss. In our study 50 patients undergoing coronary artery bypass grafting were included in a blind-randomized basis. Two main criteria were used for the eligibility of patients for coronary artery bypass grafting: ejection fraction between 30-40%, and patients receiving ACE inhibitors, at least for four weeks preoperatively. The patients were randomly divided in two groups, the group A who were infused with 0.03 IU/min vasopressin and the group B who were infused with normal saline intraoperativelly and for the 4 postoperative hours. Measurements of mean artery pressure (MAP), central venous pressure (CVP), systemic vascular resistance (SVR), ejection fracture (EF), heart rate (HR), mean pulmonary artery pressure (MPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were performed before, during, and after the operation. The requirements of catecholamine support, the urine-output, the blood-loss, and the requirements in blood, plasma and platelets for the first 24 hours were included in the data collected. The incidence of vasodilatory shock was significantly lower (8% vs 20%) in group A and B respectively (p = 0,042). Generally, the mortality was 12%, exclusively deriving from group B. Postoperatively, significant higher values of MAP, CVP, SVR and EF were recorded in the patients of group A, compared to those of group B. In group A norepinephrine was necessary in fewer patients (p = 0.002) and with a lower mean dose (p = 0.0001), additive infusion of epinephrine was needed in fewer patients (p = 0.001), while both were infused for a significant shorter infusion-period (p = 0.0001). Vasopressin administration (for group A) was associated with a higher 24 hour diuresis) (0.0001).In conclusion, low-dose of infused vasopressin during cardiopulmonary bypass and for the next 4 hours is beneficial for its postoperative hemodynamic profile, reduces the doses of requirements of catecholamines and contributes to prevention of the postcardiotomy vasoplegic shock in the patient with low ejection fraction who is receiving ACE preoperatively.

Background: The aim of this study is to explore the quality of life of elderly patients after coronary artery bypass graft (CABG) surgery., Methods: The present study employed a pre-post test design. Sixty three elderly patients (>or=65 years), operated in one big general hospital in Athens, were interviewed before, 4 months and 12 months after CABG with the MacNew Heart disease health-related quality of life questionnaire., Results: The majority of the sample were male (N=48, 76.2%), married (N=49, 77.8%) and pensioners (N=54, 61.7%). After the operation and before discharge 42 (66.6%) patients presented complications. One year after the operation, 45 (80.4%) patients experienced improvement and only 11 (19.6%) deterioration in their reported quality of life. Despite this postoperative improvement in all domains, a high percentage of patients (>60%) continued to report exacerbation in questions related to self confidence and dependence to others indicating an overprotective environment. Approximately one in two patients reported signs of cognitive dysfunction during the postoperative period. Elderly patients knew very little about their disease, especially before the operation (mean=2.03, SD=0.69, R=1-5). Educational level, presence of complications in the immediate postoperative period and reported angina were related to a poorer QoL., Conclusion: A high proportion of the patients experienced improvement while a substantial number had exacerbations related to self confidence and dependence to others. An important step to improve this situation might be through the institution of a structured multi-disciplinary rehabilitation program with focus on emotional support, information giving and education to elderly CABG patients and their significant others.

"Directed cardioplegia" is a novel approach in myocardial protection in which a certain volume of cardioplegic solution is diverted into a severely diseased coronary artery after surgical occlusion of the other main branches that can be accessed by the surgeon. In this way, the surgeon is able to eliminate the cardioplegic steal from a severely stenosed vessel through other less severely diseased and/or patent arteries during the nonselective antegrade administration of cardioplegia and to protect myocardial regions, which are poorly perfused. We performed this new technique in 2 patients with severe left main coronary artery disease with excellent results.

We describe a safe, easy, and fast technique of exposing the left anterior descending artery (LAD), when this is embedded under the myocardium or excessive epicardial fat tissue, during coronary artery bypass grafting (CABG) or off-pump coronary artery bypass (OPCAB). The vessel is opened as distal as possible, then a fine intravascular probe is introduced retrogradely. Through palpation of the tip, the course of LAD is confined together with the site of distal anastomosis formation. The suggested technique minimizes the risk of injuring the vessel or ventricles, reduces the ischemia-time, and allows the performance of anastomosis as paroximal as possible in the cases of OPCAB with embedded LAD.

Introduction: Despite their suboptimal long-term patency, saphenous vein grafts are the most widely used conduits to achieve complete revascularization during coronary artery bypass grafting (CABG). Although vein storage critically impairs endothelial integrity, contradictory data concerning optimal storage solutions exist. The aim of this study is to explore any in vitro impact of cardioplegic solutions and temperature on vein grafts endothelial integrity during their storage.Materials and Methods: A single-center, prospective trial including 40 consecutive patients was conducted. Eligibility criteria included patients submitted to CABG receiving at least one vein graft. An excess segment of the graft was harvested and divided into four different parts. Each one of them was stored under different conditions; either in a conventional heparin-enriched blood solution or in a cardioplegic solution, at room temperature (20°C-22°C) and in the refrigerator (5°C). Endothelial integrity was evaluated via immunohistochemistry using an antibody against CD31.Results: Endothelial integrity (measured in a scale from 1-worst to 5-best) was significantly better after cardioplegic solution storage (2.83 ± 0.15 and 3.10 ± 0.13 in cold and room temperature, respectively) compared with storage in conventional solutions (2.23 ± 0.16 and 2.0 ± 0.15 in cold and room temperature, respectively). A significant effect of cardioplegic storage solution, as well as of cold temperature and cardioplegic solution interaction on endothelial preservation was reported, whereas storage temperature did not prove a significant factor by its own.Conclusions: Cardioplegic storage solutions result in significantly better endothelial preservation compared with conventional heparin-enriched blood solutions. The association with superior clinical outcomes remains to be proved. [ABSTRACT FROM AUTHOR]

Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

During open heart surgery the influence of a series of factors such as cardiopulmonary bypass (CPB), hypothermia, operation and anaesthesia, as well as medication and transfusion can cause a diffuse trauma in the lungs. This injury leads mostly to a postoperative interstitial pulmonary oedema and abnormal gas exchange. Substantial improvements in all of the above mentioned factors may lead to a better lung function postoperatively. By avoiding CPB, reducing its time, or by minimizing the extracorporeal surface area with the use of miniaturized circuits of CPB, beneficial effects on lung function are reported. In addition, replacement of circuit surface with biocompatible surfaces like heparin-coated, and material-independent sources of blood activation, a better postoperative lung function is observed. Meticulous myocardial protection by using hypothermia and cardioplegia methods during ischemia and reperfusion remain one of the cornerstones of postoperative lung function. The partial restoration of pulmonary artery perfusion during CPB possibly contributes to prevent pulmonary ischemia and lung dysfunction. Using medication such as corticosteroids and aprotinin, which protect the lungs during CPB, and leukocyte depletion filters for operations expected to exceed 90 minutes in CPB-time appear to be protective against the toxic impact of CPB in the lungs. The newer methods of ultrafiltration used to scavenge pro-inflammatory factors seem to be protective for the lung function. In a similar way, reducing the use of cardiotomy suction device, as well as the contact-time between free blood and pericardium, it is expected that the postoperative lung function will be improved. [ABSTRACT FROM AUTHOR]

We report the one-stage surgical management of a 68-year-old patient with renal cell carcinoma and serious hematuria combined with coronary artery disease and unstable angina. After the accomplishment of coronary revascularization without cardiopulmonary bypass, we proceeded to nephrectomy and resection of the renal tumor at the same time. The patient's postoperative course was uneventful, and at 17 months of follow-up, the patient showed no signs of recurrence. To the best of our knowledge, such a case has never been reported before in the literature. [ABSTRACT FROM AUTHOR]

The development and evolution of Greek Cardiac Surgery (GCS) has followed the international cardiothoracic surgery after the invention of cardiopulmonary bypass machine by John Gibbon in 1953. Chronologically, the development of GCS could be divided in four periods: (a) the first or essay period (1950–1960) characterized by the lack of organization, the experimentation and hesitation from the surgeons' side, and the reluctance from the patients' side to have an operation in Greece. (b) The second or stabilization period (1960–1970) is the period during which several separate cardiovascular departments were organized and performed the first valve replacement in 1964. (c) The third or “strengthening” period (1970–1985), during which Greek surgeons were trained abroad and adopted new methods and techniques of surgical therapy. The first operations of coronary artery bypass grafting and aortic aneurysm were performed (1973–1975). Various purely Cardiothoracic Centers were founded in Athens and Thessalonica and cardiac surgery became a routine operation. However, these centers were numerically not enough to cover the demand of patients in need of cardiac surgery. (d) The fourth or maturity period (1985 till today). It is characterized by the creation of private cardiac surgery departments and the gradual establishment of new university centers at the periphery, which along with the Onassis Cardiac Center, eliminated any need for patients to leave the country. [ABSTRACT FROM AUTHOR]