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Modern treatment of coronary artery disease (CAD) requires a patient-centered approach. With several technological advances, the options for treatment must be carefully weighed and novel approaches tested for safety and efficacy. In this chapter, we outline some of the new approaches available to cardiac surgeons for the treatment of CAD, including off pump coronary artery bypass grafting, minimally invasive as well as hybrid and robotic coronary revascularization. We discuss current evidence and controversies, and highlight the future directions and challenges in the field of surgical coronary revascularization., (Copyright © 2015. Published by Elsevier Inc.)

Objective: The optimal treatment of multivessel coronary artery disease is not well established. Hybrid coronary revascularization by combining the left internal mammary artery-left anterior descending artery graft and drug-eluting stents in non-left anterior descending artery territories might offer superior results compared with sole coronary artery bypass grafting or sole percutaneous coronary intervention., Methods: We retrospectively analyzed the 30-day outcomes of 381 consecutive patients undergoing coronary artery bypass grafting (n = 301) vs hybrid coronary revascularization (n = 80). In a 2 × 2 matrix, the 2 groups were stratified by the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (≤32 vs ≥33) and the European System for Cardiac Operative Risk Evaluation (euroSCORE) (<5 vs ≥5). The composite endpoint (death from any cause, stroke, myocardial infarction, low cardiac output syndrome) and secondary endpoints (worsening postprocedural renal function and bleeding) were determined., Results: After stratification using the SYNTAX and the euroSCORE, the preoperative characteristics were similar within the 4 groups, except for the ≥33 SYNTAX/>5 euroSCORE. The hybrid coronary revascularization patients were older (77 vs 65 years, P = .001). The postoperative outcomes using combined SYNTAX and the euroSCORE stratification showed a similar rate of the composite endpoint for all groups except for patients with ≥33 SYNTAX/>5 euroSCORE (0% for the coronary artery bypass grafting group vs 33% for the hybrid coronary revascularization group, P = .001). An analysis of the secondary endpoint showed similar results across all groups, except for in the ≥33 SYNTAX/>5 euroSCORE group, in which bleeding (re-exploration for bleeding and transfusion >3 packed red blood cell units per patient) was 44% in the hybrid coronary revascularization group vs 11% in the coronary artery bypass grafting group (P = .05)., Conclusions: Hybrid coronary revascularization is a safe alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. However, in high-risk patients with complex coronary artery disease (≥33 SYNTAX/>5 euroSCORE), coronary artery bypass grafting is superior to hybrid coronary revascularization., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Hybrid coronary revascularization combines coronary artery bypass surgery with percutaneous coronary intervention techniques to treat coronary artery disease. The potential benefits of such a technique are to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery. Hybrid coronary revascularization has resulted in the establishment of new 'hybrid operating suites', which incorporate and integrate the capabilities of a cardiac surgery operating room with that of an interventional cardiology laboratory. Hybrid coronary revascularization has greatly augmented teamwork and cooperation between both fields and has demonstrated encouraging as well as good initial outcomes.

Graft patency strongly influences early and late outcomes after coronary artery bypass grafting (CABG) surgery. The current standard of care in CABG surgery does not require intraoperative imaging. Because coronary angiography is rarely available in the operating room (OR), other techniques have been developed to assess graft integrity intraoperatively. The 2 most commonly used are the transit time flow measurement (TTFM) and the intraoperative fluorescence imaging (IFI). The TTFM is a quantitative volume flow technique, whereas the IFI is based on the fluorescent properties of indocyanine green. TTFM cannot define the degree of graft stenosis nor discriminate between the influence of the graft conduit and the coronary arteriolar bed on the mean graft flow. IFI provides a "semiquantitative" assessment of the graft patency with images that provide some details about the quality of coronary anastomoses. Both methods are valuable in identifying only at the extremes, that is, either patent or occluded grafts, and can confirm very good grafts; however, neither method is sensitive or specific enough in identifying more subtle abnormalities. These abnormal grafts most likely have poor long-term patency and are predestined to fail. The hybrid suite has the capability of serving both as a complete surgical OR and as a catheterization laboratory. It allows for routine completion angiogram following CABG surgery and identifies abnormal grafts, providing the opportunity to revise them with percutaneous coronary intervention or surgery before leaving the OR.

Objectives: This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room., Background: The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved., Methods: Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings., Results: Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients., Conclusions: Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

Aim: In patients with unstable angina (UA) undergoing nonelective myocardial revascularization we compare the outcomes of skeletonized bilateral internal mammary arteries (BIMA) vs left internal mammary artery (LIMA) and saphenous vein grafts (SVGs) vs SVGs only., Methods: Between January 1997 and December 2003, 758 patients: 612 (80.7%) males, mean age 62+/-12 years, underwent nonelective coronary artery bypass grafting (CABG) for unstable angina; 205 (27%) were operated emergently and 553 (73%) urgently. BIMA were employed in 320 (42%) patients (Group B) , isolated LIMA and/or SVGs in 332 (44%) patients (Group M) and only SVGs in 106 (14%) (Group S)., Results: In-hospital mortality (B=5.9%, M=4.5% and S=7.5%), and perioperative myocardial infarction (B=2.2%; M=1.9%, S=3.7%) were similar between the 3 groups (P=NS). Actuarial survival at 1, 3 and 7 years was 98.7%, 97.5% and 96.2% in group B, 99.3%, 94.8% and 89.4% in group M (P< 0.057 at 7 years follow-up) and 98%, 93.2% and 84.3% in group S (P=0.001). At 7 years follow-up, the event-free cardiac survival (92% vs 89.1%, P=0.045), angina-free survival (98.6% vs 95.8%, P=0.056), reoperation-free cardiac survival (98% vs 96%, P= 0.05) and infarct-free cardiac survival (98.7% vs 96.9%, P=0.062) showed a consistent trend to be superior in group B. Multivariate analysis identified age >65 years (P= 0.02), left ventricular ejection fraction (LVEF) <35% (P= 0.01), >1 ischemic irreversible area (P= 0.03) as independent predictors for late deaths, while the use of the LIMA (P= 0.006) and both mammary arteries (P= 0.001) decreased the risk of late deaths., Conclusions: The use of BIMA in nonelective CABG for UA is safe and effective. There is a trend, however, toward a survival benefit with improved freedom from late cardiac events (recurrence of angina, freedom from reoperation and infarction).

Mitral valve regurgitation (MVR), occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction, predicts a poor outcome in terms of survival and morbidity. Between 1995 and 2003, 180 consecutive patients with impaired LV function and chronic ischemic MVR underwent cardiac surgery. Fifty-four patients (group I), MVR (grade III-IV) underwent simultaneous MV surgery and coronary artery bypass grafting (CABG); 40 patients (group II), MVR (grade II-III), and 86 patients (group III), MVR (grade I-II), underwent CABG alone. In group I, MV repair was performed in 36 patients (group IA) and MV replacement in 18 (group IB). The incidence of hospital death was similar between groups. The actuarial event-free survival was significantly lower in group than in groups II and III (P = 0.0045) and I (P = 0.038). The overall actuarial survival was significantly higher in group IA than in group IB (P = 0.027). Postoperatively, the LV ejection fraction (P < 0.001), LV end-diastolic diameter (P < 0.001), LV end-systolic diameter (P < 0.01), and cardiac index (P < 0.001) improved significantly in group I. The regurgitation fraction decreased significantly in Groups I and III after surgery (P < 0.001 and P = 0.003, respectively). Both MV repair and replacement that preserves subvalvular apparatus in patients with end-stage ischemic myocardiopathy offer an acceptable outcome. Mitral valve repair simultaneous to CABG improves significantly the LV function and its geometry. In patients with mild to moderate mitral regurgitation, CABG alone may be performed with good overall survival, but with lower event-free survival than those undergoing concomitant mitral valve repair.

Background: We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk., Methods: Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%)., Results: Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p < 0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor., Conclusions: Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Background: Surgical revascularization employing bilateral internal mammary arteries (IMAs) is an excellent procedure in elective surgery, but its role in urgent/emergent procedures is still debating. This retrospective study evaluates the feasibility, safety and surgical early outcomes of employing double skeletonized IMAs in patients with unstable angina (UA) undergoing urgent/emergent revascularization., Methods: From January 1997 to May 2004, 824 patients (491 males, 333 females, mean age 64 +/- 12 years) underwent urgent revascularization for UA. Bilateral IMAs were employed in 346 (42%) patients (group B) and isolated and/or saphenous vein grafts in the remaining 478 (58%) patients (group M). There were no significant differences in preoperative risk factors between the two groups (mean EuroSCORE value)., Results: Postoperative stay was free from complications in 87% of patients of group B and 91% of group M. In-hospital mortality (group B 5.9%, group M 5.3%, p = NS) and perioperative myocardial infarction (group B 2.2%, group M 1.96%, p = NS), mean coronary care unit stay and total hospital stay were similar in both groups. Actuarial survival at 1, 3, 5 and 7 years was respectively 98.7, 97.5, 96.9 and 96.1% in group B and 99, 93.4, 92.1 and 88.4% in group M (p < 0.05). At a mean follow-up of 6.6 years the event-free survival (p = 0.021) and reoperation-free cardiac survival (p = 0.003) were better in group B. Multivariate analysis identified that age > 65 years (p = 0.01), congestive heart failure (p = 0.001), left ventricular ejection fraction < 35% (p = 0.03), and > 1 ischemic irreversible area (p = 0.02) are negative predictors for reoperation-free cardiac survival. The employment of the left IMA (p = 0.006) and of both IMAs (p = 0.001) were positive predictors for the overall survival and reoperation-free cardiac survival., Conclusions: Our results show that the use of skeletonized bilateral IMAs is associated with an acceptable risk and a lower incidence of postoperative complications in patients with UA, improving late outcomes in this group of patients.

This retrospective study of cardiac surgical patients with normal serum creatinine who developed acute renal failure requiring artificial renal support was undertaken to (1) determine the prevalence of acute renal failure and hospital mortality in this subgroup, (2) identify the independent predictors of early mortality, and (3) determine long-term survival and prognosis.

Objectives: The aims of this study were as follows: 1) to evaluate the early outcome of the off-pump total arterial myocardial revascularization according to the right y-graft (lambda-graft) configuration and 2) to compare baseline flow and maximum flow between patients undergoing on-pump and off-pump right y-graft (RYG) construction., Methods: Between December 1998 and January 2001, 47 patients (Group I) and 20 patients (Group II) with three vessel disease underwent on-pump and off-pump coronary artery bypass graft (CABG) respectively according to the RYG configuration. The mean age was 55.5 +/- 4.7 years and 55 +/- 6.4 years in Groups I and II, respectively. The RYG was constructed employing both internal mammary arteries (IMAs) only, in 21 and 8 patients in Groups I and II, respectively, presenting proximal-middle third stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA). The modified RYG configuration employing both IMAs and radial artery (RA) was performed in 26 and 12 patients in Groups I and II, respectively, presenting middle-distal third stenosis of the LAD and distal stenosis of the RCA or posterior descending artery stenosis. Postoperatively all patients underwent transthoracic echo color-Doppler (TTECD) contrast enhanced (by Levovist) before and after adenosine provocative testat one week and three months after operation., Results: There were no hospital deaths. The mean mechanical ventilation was significantly different in Group I versus Group II patients, 18 +/- 4.4 hours versus 13 +/- 5.7 hours, respectively (p = 0.041). The mean intensive care unit stay was 1.5 +/- 0.6 days in Group I and 1 +/- 0.4 days in Group II (p = 0.033). There were no differences between Groups I and II regarding the IMA diameter, mean velocity, and mean flow. At follow-up time, 6 +/- 2.4 months after the surgical procedure, all patients were alive and free of angina. The coronary flow reserve (CFR) at LIMA main stem was significantly higher at three months when compared to the values at one week after the surgical procedure within the same group, (LIMA)CFR (three months) = 2.37 +/- 0.6 versus (LIMA)CFR (one week) = 2.07 +/- 0.4 (p = 0.005) in Group I and (LIMA)CFR (three months) = 2.4 +/- 0.4 versus (LIMA)CFR (one week) = 2.06 +/- 0.3 (p = 0.004) in Group II. Similarly, the CFR at RIMA main stem were significantly higher at three months when compared to the values at one week after the surgical procedure: (RIMA)CFR (three months) = 2.47 +/- 0.7 versus (RIMA)CFR (one week) = 2.1 +/- 0.5 (p = 0.004) in Group I and (RIMA)CFR (three months) = 2.48 +/- 0.5 versus (RIMA)CFR (one week) = 2.08 +/- 0.4 (p = 0.008) in Group II., Conclusion: The flow dynamic data, almost identical between patients undergoing off-pump and on-pump total arterial myocardial revascularization (TAMR) according to the RYG configuration, demonstrate that this technique can be applied with excellent results without the employment of cardiopulmonary bypass in selected coronary artery disease patients.

Background: As patients referred for cardiac surgery include increasingly older individuals, the prevalence of comorbid factors, such as previous cerebrovascular disease, carotid disease, aortic atherosclerosis, and reoperations, is on the rise. Avoiding manipulation of the ascending aorta in this high-risk subgroup may become a necessity to perform safe coronary artery bypass grafting (CABG) surgery., Methods: We retrospectively reviewed our database of 640 off-pump CABG patients and identified 84 patients in whom we adopted the "no touch" technique (NTT). Revascularization was carried out with single or bilateral internal thoracic arteries (ITA) and by connecting additional coronary grafts (saphenous vein, radial artery) in a T or Y configuration. The right gastroepiploic artery was used as a conduit in 2 patients. The brachiocephalic artery was used as an alternative inflow site in 3 patients (reoperation)., Results: Age, sex, risk factors, functional class, and history of congestive heart failure were comparable in the two groups. In the NTT group, the frequencies were higher for severe atherosclerosis of the aorta (13% versus 0%; P =.00), carotid disease (25% versus 16%; P =.02), and history of previous cerebrovascular accidents (17% versus 8%; P =.04). Complete revascularization was achieved in 96% of the patients in the off-pump CABG group, compared with 90% in the NTT group (P =.17). No differences in the prevalence of postoperative low cardiac output syndrome, intra-aortic balloon pump use, perioperative myocardial infarction, or operative mortality at 30 days were observed between the two groups. In the NTT group, weak trends toward a lower incidence of postoperative delirium (8% versus 15%; P =.12), a lower incidence of stroke (0% versus 1%; P =.85), and a shorter intensive care unit stay (P =.07) were observed. Hospital stay was also shorter in the NTT group (P =.04)., Conclusion: Avoiding aortic manipulations in patients with severe atherosclerosis of the aorta, carotid disease, and a previous history of cerebrovascular accidents is technically feasible and is associated with a low risk of mortality and good shortterm results. Adopting this practice may reduce the incidence of stroke and improve early outcome in this subset of patients.

Accessory mitral valve leaflet is a very rare cause of left ventricular outflow tract obstruction. We report a patient presenting this cardiac abnormality who undergone cardiac surgery. A 60-year-old man, presented coronary artery disease and moderate left ventricular tract obstruction due to accessory mitral valve leaflet. The accessory mitral valve leaflet had the typical morphology of a parachute-shaped attached partially to the anterior mitral valve leaflet, with chordae tendinae attached to: 1) an accessory papillary muscle inserted at the free-wall closed to the apex; 2) interconnected with the chordae tendinae of the anterior mitral valve leaflet; 3) a second accessory papillary muscle inserted to the interventricular septum. He underwent successful coronary revascularization of 2 vessels and accessory leaflet excision. A review of 21 cases with accessory mitral valve leaflet is reported.

Background: The use of skeletonized internal thoracic artery (ITA) was reported to be technically and hemodynamically beneficial in conventional coronary artery bypass grafting with cardiopulmonary bypass assistance. The purpose of this study is to evaluate the impact of changing from conventional to skeletonized ITA harvesting on early off-pump coronary artery bypass grafting outcome., Methods: Between 1996 and 2001, 640 patients underwent systematic off-pump coronary artery bypass grafting (single surgeon experience). The ITA was pedicled (P) in the first consecutive 440 patients and skeletonized (S) in the subsequent 200 consecutive patients. Mean age, preoperative risk factors, sex, number of involved territories, and incidence of reoperations were similar in both groups., Results: In group S, number of ITAs per patient (1.7 +/- 0.08 versus 1.2 +/- 0.05; p < 0.001), bilateral ITA (46% versus 27%; p < 0.001), ITA sequential grafts (27% versus 1%; p < 0.001), and T grafts (16% versus 3%; p < 0.001) were higher. Deep sternal infections were comparable in both groups (group S: 1%, group P: 1.2%; p = 0.38). Perioperative myocardial infarction, maximal creatinine kinase-MB level, and requirement for more than 24 hours of inotropic support were comparable in both groups. Thirty-day mortality was also similar (S: 1.7%, P: 1.6%)., Conclusions: Changing to routine use of skeletonized ITA in off-pump coronary artery bypass grafting is a safe alternative to routine pedicled ITA. In our experience, this procedure has facilitated the use of ITA anastomosis without increasing sternal wound complications.

Six cases of spontaneous coronary arteries dissection are reported. In one patient, triple vessel spontaneous coronary artery dissection was identified. Another patient presented spontaneous left main coronary artery dissection. In one case we found the spontaneous dissection of the left anterior descending artery associated with distal aortic arch dissection. These conditions are very rare and may present a surgical dilemma. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention is safe and effective. Early recognition of left main coronary artery dissection or three-vessel dissection is essential because urgent coronary artery bypass grafting may be life saving.

Background: The aim of the multicenter OP-RISK (OPerative RISK) study was to investigate the early (28 days) and delayed (365 days) death rates following coronary artery bypass grafting (CABG) among patients representing a nationwide distribution [Centers in Northern (2), Central (1) and Southern (1) Italy] and further to define the multivariate risk factors for the early and delayed mortality after CABG., Methods: Data were collected from 1126 patients undergoing CABG alone. Data were analyzed using Cox and logistic regression models, to accurately assess the major factors influencing survival over time after CABG. Having defined the significant factors, we constructed a chart of the absolute early risk of mortality using the accelerated failure time model., Results: Using the Cox proportional hazards model and logistic regression we have demonstrated that age, preoperative ejection fraction and heart rate, and the duration of aortic cross-clamping are multivariate risk factors in the short and long term. The role of one arterial conduit was also assessed., Conclusions: The OP-RISK study produced relevant information for risk assessment and control in CABG and the results may form the basis for the objective quality assurance and accreditation of cardiac surgical institutions in Italy. Incidentally, Cox model appeared more adequate than logistic model for the assessment of the major factors influencing survival over time after CABG. The risk factors so assessed were used to construct a chart for practical predictive purposes.

Background and Objectives: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG., Patients and Methods: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis., Results: CPB time was significantly longer in Group I, 127+/-21 minutes versus 98+/-11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II., Conclusions: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.

Objectives: To evaluate in a cohort of ESCAD patients (pts) the effects of on-pump/beating-heart versus conventional CABG in terms of early and mid-term survival and morbidity and LV function improvement., Methods: Between January 1993 and December 2000, 78 (Group I) ESCAD pts underwent on-pump/beating-heart surgery. Mean age in Group I was 66.2+/-6 (58-79), NYHA and CCS class were 3.2+/-0.6 and 3.3+/-0.4 respectively, Myocardial viability index 0.69+/-0.1 (%), LVEF (%) 24.8+/-4, LVEDP (mmHg) 28.1+/-5.8 and LVEDD(mm) 69.5+/-6. Group II consisted in 78 ESCAD patients undergoing conventional CABG selected in a randomized fashion from an age, sex, and LVEF corrected group of patients. Mean age in Group II was 65.7+/-5 (57-78), NYHA 3.1+/-0.7, CCS 3.4+/-0.8, LVEF(%) 25+/-5, LVEDP(mmHg) 27.9+/-4.4 and LVEDD(mm) 69.2+/-7.2., Results: Postoperatively, 5(7.7%) patients died in Group I versus 7(11.5%) patients in Group II (P>0.1). CPB time resulted to be in Group II patients (P=0.001) and the mean distal anastomoses per patient was similar between groups (P=Ns). Perioperative AMI (P=0.039), LCOS (P=0.002), necessity for ultrafiltration (P=0.018) and bleeding>1000 ml (P=0.029) were significantly higher in Group II. None of the Group I patients underwent surgical revision for bleeding versus 8(10.3%) patients in Group II (P=0.011). At 6 months after surgery, the LV function improved significantly in Group I patients, demonstrated by an increased LVEF=27.2+/-4(%)(P=0.001), lower LVEDP=26.4+/-3(mmHg)(P=0.029) and LVEDD=67+/-4(mm) (P=0.004) instead of a lower LVEDD=66.8+/-6(mm)(P=0.032) versus the preoperative data in Group II. The actuarial survival at 1, 3 and 5 yr were 90, 82 and 71% in Group I and 89, 83 and 74% in Group II (P=Ns)., Conclusion: In ESCAD patients who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers a better myocardial and renal protection associated with lower postoperative complications due to intraoperative hypoperfusion.

Introduction: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic MR and impaired LV function., Materials and Method: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5 +/- 5, 67.7 +/- 7,27.7 +/- 4, and 51.4 +/- 7, respectively in group 1 versus 27.8 +/- 4, 67.5 +/- 6, 27.5 +/- 5, and 51.2 +/- 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild-to-moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients., Results: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group 1 versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow-up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.5%) of 43 patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009)., Conclusion: MV repair and replacement-preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild-to-moderate and moderate MR in patients with impaired LV function should be taken into consideration since it yields better survival and improved LV function.

Background: The aim of this study was to evaluate the outcome and flow dynamics of the lambda graft configuration, relative to a second arterial graft., Methods: From 1998 to 2000, 47 patients (mean age 55.5 +/- 4.7 years) with triple-vessel disease underwent arterial revascularization using the lambda graft. The in situ left internal mammary artery (LIMA) and right internal mammary artery (RIMA) were anastomosed to the left anterior descending (LAD) and obtuse marginal arteries, respectively. In 21 patients (group I) presenting proximal or middle-third LAD or right coronary (RC) arterial stenoses, the lambda graft was constructed by anastomosing the distal LIMA, as a free LIMA graft, to the RC and proximally to the in situ RIMA. In the other 26 patients (group II) presenting with middle-distal third LAD or RC arterial stenoses, the radial artery (RA) was used to construct the lambda graft. All patients underwent transthoracic echo color Doppler before and after an adenosine test at 1 week and 3 months after operation., Results: There were no hospital deaths. Overall, 47 lambda grafts were constructed. There was no difference between baseline and maximal flows and coronary flow reserve (CFR) between groups. CFR at IMA stems increased in both groups within 3 months versus 1 week [(LIMA)CFR = 2 +/- 0.3 vs 2.3 +/- 0.3 (p = 0.002) and (RIMA)CFR = 2.2 +/- 0.4 vs 2.5 +/- 0.3 (p = 0.009) in group I, and (LIMA)CFR = 2.12 +/- 0.33 vs 2.4 +/- 0.35 (p = 0.005) and (RIMA)CFR = 2.17 +/- 0.32 vs 2.52 +/- 0.26 (p = 0.001) in group II]. At 3 months versus 1 week, the (RIMA)diameter(i) (mm) at rest was 1.69 +/- 0.32 versus 1.48 +/- 0.2 (p = 0.015) in group I and 1.66 +/- 0.3 versus 1.47 + 0.2 (p = 0.01) in group II. At 6 +/- 2.4 months, all patients were free of angina., Conclusions: These data, almost identical for free LIMA and RA to RIMA using the lambda graft, demonstrate that RIMA flow reserve is adequate for multiple coronary anastomoses irrespective of the second arterial graft.

Objectives: The purpose of our study was to evaluate in a cohort of end-stage coronary artery disease (ESCAD) patients the effects of on-pump/beating-heart versus conventional coronary artery bypass grafting (CABG) requiring cardioplegic arrest. We report early and midterm survival, morbidity, and improvement of left ventricular (LV) function., Methods: Between January 1992 and October 1999, 107 (Group I) ESCAD patients underwent on-pump/beating-heart surgery and 191 (Group II) ESCAD patients underwent conventional CABG requiring cardioplegic arrest. Mean age in Group I was 65.8 +/- 6.5 years (58-79 years); New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classifications were 3.2 +/- 0.4 and 3.3 +/- 0.5, respectively. LV ejection fraction (LVEF) was 24.8% +/- 4%, LV end diastolic pressure (LVEDP) was 28.2 +/- 3.8 mmHg, and LV end diastolic diameter (LVEDD) was 69.6 +/- 4.6 mm. Mean age in Group II was 64.1 +/- 5 years (57-76 years), NYHA class was 3 +/- 0.6, CCS class was 3.4 +/- 0.4, LVEF was 26.2% +/- 4.3%, LVEDP was 27.2 +/- 3.4 mmHg, and LVED was 68 +/- 4.2 mm., Results: Preoperatively, Group I patients versus Group II patients had a markedly depressed LV function (LVEF, p = 0.006; LVEDP, p = 0.02; LVEDD, p = 0.003; and NYHA class, p = 0.002), older age (p = 0.012), and higher incidences of multiple acute myocardial infarction (AMI; p = 0.004), cardiovascular disease (CVD; p = 0.008), and chronic renal failure (CRH, p = 0.002). Cardiopulmonary bypass (CPB) time was longer in Group II patients (p = 0.028). The mean distal anastomosis per patient was similar between groups (p = NS). Operative mortality between Groups I and II was 7 (6.5%) and 19 (10%), respectively (p = NS). Perioperative AMI (p = 0.034), low cardiac output syndrome (LCOS; p = 0.011), necessity for ultrafiltration (p = 0.017), and bleeding (p = 0.012) were higher in Group II. Improvement of LV function within 3 months after the surgical procedure was markedly higher in Group I, demonstrated by increased LVEF (p = 0.035), lower LVEDP (p = 0.027), and LVEDD (p = 0.001) versus the preoperative data in Group II. The actuarial survivals at 1, 3, and 5 years were 95%, 86%, and 73% in Group I and 95%, 84%, and 72% in Group II (p = NS)., Conclusions: ESCAD patients with bypassable vessels to two or more regions of reversible ischemia can undergo safe CABG with acceptable hospital survival and mortality and morbidity. In higher risk ESCAD patients, who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers better myocardial and renal protection associated with lower postoperative complications.

Background: Total arterial myocardial revascularization (TAMR) is feasible because of the excellent long-term patency of the arterial conduits. We present five new surgical configurations for TAMR., Methods: Between December 1998 and July 1999, 34 patients with triple vessel disease underwent TAMR. All patients were in CCS III or IV. Sketelonized internal mammary arteries (IMAs) were used. The surgical techniques for TAMR consisted of Y or T composite grafts constructed between the in situ RIMA and free LIMA graft or radial artery (RA) conduit in three different configurations. Other techniques uses included a T graft constructed between the RA conduit and free LIMA graft in two configurations. Twenty-six (76%) patients underwent contrast-enhanced TTE color Doppler before and after adenosine provocative test, and seven (20%) patients had postoperative coronary angiography., Results: Overall, 144 anastomoses (average number per patient, 4.2) were completed. One (2.9%) patient undergoing an inverted T graft technique died on postoperative day 2. Another patient (2.9%) undergoing the right Y graft technique using IMAs and RA suffered perioperative AMI due to RA conduit vasospasm. Contrast-enhanced TTE color Doppler before and after the adenosine provocative test and at 1 week postoperation revealed a coronary flow reserve (CFR) of 2.1 +/- 0.2 in the LIMA stem, and in the RIMA stem, a CFR of 2.3 +/- 0.3 (P < 0.007). In one patient undergoing the right Y graft technique using IMAs, we found only anomalous flow dynamic parameters of RIMA, suggesting a partial graft closure. The angiographic examination revealed a free LIMA graft closure. At 6 +/- 2.4 months after operation 33 patients were alive and free of angina. The IMAs stem evaluation by TTE color Doppler at follow-up revealed a 2.45 +/- 0.1 mm LIMA diameter and 2.6 +/- 0.2 mm RIMA diameter, which was more than early postoperative data of P < 0.001 and P < 0.007, respectively., Conclusion: These data indicate that TAMR in young patients perhaps offers a better postoperative outcome and perhaps should be part of the surgical armamentarium. These techniques apply the "nontouch" principle and should be taken into consideration in patients with a heavily calcified aorta. Contrast-enhanced TTE color Doppler is a safe, accurate, and noninvasive test, which allows assessment of IMA patency and CFR evaluation. The flow reserve of the IMAs seems to be adequate for multiple coronary anastomoses.

The multicenter OP-RISK study, developed during 1994-96, was aimed at: 1) investigating early (28 days) death rates following aortocoronary bypass surgery among patients recruited from four Centers representing geographical distribution in Italy; 2) defining possible risk factors for early mortality, also comparing these factors with those reported in previous studies. Average values are reported and compared of 65 variables (36 preoperative, 10 operative and 19 postoperative) out of 984 patients subdivided into alive (n = 940) or dead (n = 44, 4.47%) at 28 days (155 +/- 174 hours, interval between 12 and 576 hours) postoperatively. Causes of death were cardiac in 37 (77%), pulmonary in 3 (0.7%), vascular in 2 (0.5%) and infective in 2(0.5%) patients, respectively. During the study a total of 1126 patients were operated upon in the collaborative Centers with the diagnosis of coronary artery disease and 51 deaths were reported officially in-hospital (4.53%). Therefore, OP-RISK data represent 87% of overall patients and a superposable death rate. The potential role as risk factors of early mortality was assessed univariately for 17 preoperative, 5 operative (in 3 cases for the first time) and 5 postoperative factors. In general, it was confirmed that factors defining left ventricular function are sensitive predictors of mortality. In OP-RISK we were able to show, in addition, that tachycardia (> 130 b/min) at induction of anesthesia, and total time of anesthesia, cardiopulmonary bypass and aortic cross clamping may be significant factors among operative variables as might be among postoperative ones several arrhythmia types or a lower rate in antithrombotic therapy with aspirin at 6-12 hours postoperatively. The protective role of bypass surgery performed with at least 1 arterial segment was also ascertained. Most of these potential factors were significantly related to outcome (either directly or inversely) as were among them, as seen in a subsample (65%) of 639 patients in whom a correlation matrix was performed among 16 factors selected on the basis of the common denominator principle. Our results suggest that it is possible to collect in a multicenter experience univariate predictors of early mortality following aortocoronary bypass surgery in Italy, which are not different from those reported from previous studies performed abroad. Operative indicators may also have predictive capabilities. The effort may be worthwhile and demands further cooperative studies to be undertaken, aimed at obtaining nationwide coefficients of risk along with representative average values of factors that soon might emerge once multivariate statistics will be performed on this material.