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The present study investigates why shedding of the endothelial glycocalyx occurs both in patients undergoing on- and off-pump coronary artery bypass surgery. Release of atrial natriuretic peptide (ANP) was of special interest, because ANP initiates shedding ex vivo. Three major constituents of the glycocalyx (syndecan-1, heparan sulfate and hyaluronan) were measured in arterial blood of patients undergoing coronary artery bypass surgery with (n = 15) and without (n = 15) cardiopulmonary bypass at various phases of the procedure. Additionally, the levels of the inflammatory cytokines interleukin (IL)-6, -8, and -10 and of ANP were evaluated. Elevations of all three components of the glycocalyx were detected in blood of patients undergoing on- (maximum increases: syndecan-1 15-fold, heparan sulfate ninefold, hyaluronan fivefold basal) and off-pump (maximum increases: syndecan-1 fourfold, heparan sulfate twofold, hyaluronan threefold basal) coronary artery surgery. Maximum ANP concentrations increased three- and fourfold basal in on- and off-pump coronary artery surgery, respectively (P < 0.05). There were significant increases in the three cytokine concentrations in both on- (maximum increases: IL-6 146-fold, IL-8 23-fold, IL-10 238-fold basal) and off-pump (maximum increases: IL-6 77-fold, IL-8 eightfold, IL-10 58-fold basal) coronary artery surgery. However, the elevations of ANP preceded those of the cytokines and coincided with or even preceded shedding of the human endothelial glycocalyx in both surgical procedures. These data suggest that release of ANP may lead to perturbation of the endothelial glycocalyx in both on- and off-pump coronary artery bypass surgery.

In an aging population, numerous patients who underwent previous coronary artery bypass grafting (CABG) are presenting with end-stage ischemic cardiomyopathy. Although redo CABG and cardiological interventions are possible treatment options, orthotopic heart transplantation remains an ultimate option for these patients. However, there is high morbidity and mortality on the waiting list, and mechanical circulatory support is a life-saving concept [Hetzer 2006; Taylor 2009].We developed a simplified and safe technique for implantation of a biventricular assist device as a redo in complex patients after previous CABG and end-stage heart failure.

The most common causes of myocardial ischemia and myocardial infarction early after coronary artery bypass grafting surgery are early graft occlusion/thrombosis or occlusion/ thrombosis of coronary arteries due to advanced coronary heart disease. We describe a case of postoperative myocardial ischemia due to an uncommon and quickly reversible cause: mechanical compression of a vein graft by a 19F flexible silicone mediastinal drainage tube.

Objectives: The purpose of this randomized study was to compare sirolimus-eluting stenting with coronary artery bypass grafting (CABG) for patients with unprotected left main (ULM) coronary artery disease., Background: CABG is considered the standard of care for treatment of ULM. Improvements in percutaneous coronary intervention (PCI) with use of drug-eluting stents might lead to similar results. The effectiveness of drug-eluting stenting versus surgery has not been established in a randomized trial., Methods: In this prospective, multicenter, randomized trial, 201 patients with ULM disease were randomly assigned to undergo sirolimus-eluting stenting (n = 100) or CABG using predominantly arterial grafts (n = 101). The primary clinical end point was noninferiority in freedom from major adverse cardiac events, such as cardiac death, myocardial infarction, and the need for target vessel revascularization within 12 months., Results: The combined primary end point was reached in 13.9% of patients after surgery, as opposed to 19.0% after PCI (p = 0.19 for noninferiority). The combined rates for death and myocardial infarction were comparable (surgery, 7.9% vs. stenting, 5.0%; noninferiority p < 0.001), but stenting was inferior to surgery for repeat revascularization (5.9% vs. 14.0%; noninferiority p = 0.35). Perioperative complications including 2 strokes were higher after surgery (4% vs. 30%; p < 0.001). Freedom from angina was similar between groups (p = 0.33)., Conclusions: In patients with ULM stenosis, PCI with sirolimus-eluting stents did not show noninferiority [corrected] to CABG at 12-month follow-up with respect to freedom from major adverse cardiac events, which is mainly influenced by repeated revascularization, whereas for hard endpoints, [corrected] PCI results are favorable. A longer follow-up is warranted. [corrected], (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Since 2002 MI and stroke, not cancer, are leading causes of death in women. We studied 30-days and 1 year mortality of 3441 patients undergoing coronary artery bypass grafting (CABG) operations in our institution performed either conventionally or off pump (OPCAB). Our objective was to investigate the gender-related mortality in both groups., Patients and Methods: Between 2004 and 2008, 3441 patients (733 women, 2708 men) underwent CABG. 252 women and 854 men were operated using OPCAB, 481 women and 1854 men using extracorporeal circulation (ECC). Medical data was prospectively entered and retrospectively reviewed. 30-days and one year mortality rates were analyzed with Kaplan-Meier estimates and Cox proportional hazards models. Linear and logistic regression models were used to test gender differences., Results: a) 30-day mortality using ECC: 5.2% in women vs. 2.5% in men (p = 0.001). One year ECC mortality: 8.7% in women vs. 4.8% in men (p = 0.0008). b) OPCAB: 30-days and 1 year mortality in women measured 1.7%. Mortality in men was 2.1% after 30 days and 3.7% after one year c) gender specific mortality: 30 days mortality in women was 1.7% using OPCAB and 5.2% using ECC (p = 0.002), one year mortality in women was 1.7% using OPCAB vs. 8.7% using ECC (p = 0.0004). In men, 30-days mortality in OPCAB was 2.1%, one year mortality was 3.7%; using ECC early and late mortality was 2.5% and 4.8%., Conclusions: Female gender is a strong independent predictor and risk factor of increased early and midterm postoperative mortality rates when ECC is used. OPCAB significantly reduces early and midterm postoperative mortality in women and may therefore be proposed as the preferred revascularization technique in female patients.

The number of percutaneous coronary interventions (PCI) prior to coronary artery bypass grafting (CABG) increased drastically during the last decade. Patients are referred for CABG with more severe coronary pathology, which may influence postoperative outcome. Outcomes of 200 CABG patients, collected consecutively in an observational study, were compared (mean follow-up: 5 years). Group A (n = 100, mean age 63 years, 20 women) had prior PCI before CABG, and group B (n = 100, mean age 66, 20 women) underwent primary CABG. In group A, the mean number of administered stents was 2. Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 54 vs 34 (P = 0.007), distribution of CAD (P < 0.0001), unstable angina: 27 vs 5 (P < 0.0001). For intraoperative data, the total number of established bypasses was 2.43 +/- 1.08 vs 2.08 +/- 1.08 (P = 0.017), with the number of arterial bypass grafts being: 1.26 +/- 0.82 vs 1.07 +/- 0.54 (P = 0.006). Regarding the postoperative course, significant results could be demonstrated for: adrenaline dosage (0.83 vs 0.41 mg/h; [p is not significant (ns)]) administered in 67 group A vs 47 group B patients (P = 0.006), and noradrenaline dosage (0.82 vs 0.87 mg/h; ns) administered in 46 group A vs 63 group B patients (P = 0.023), CK/troponine I (P = 0.002; P < 0.001), postoperative resuscitation (6 vs 0; P = 0.029), intra aortic balloon pump 12 vs 1 (P = 0.003), and 30-day mortality (9% in group A vs 1% in group B; P = 0.018). Clopidogrel was administered in 35% of patients with prior PCI and in 19% of patients without prior PCI (P = 0.016). Patients with prior PCI presented for CABG with more severe CAD. Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI.

Among coronary artery anomalies, single coronary artery is one of the rarest anomalies. Pulmonary origins of the coronary arteries, coronary artery fistulae, and anomalous aortic origins of the coronary arteries are the most common anomalies requiring surgical intervention. In this case, we describe the performance of bypass grafting after unsuccessful attempts at percutaneous coronary intervention in a 72-year old male patient with single coronary artery arising from the right sinus of Valsalva and with associated diffuse coronary atherosclerosis. Intraoperative angiography was performed to evaluate the revascularization of this anomalous coronary system. The patient remains symptom free 6 months after the operation.

Background: Increasing numbers of patients with advanced coronary artery disease have limited options for percutaneous and/or surgical revascularization. A prospective, randomized, phase I clinical multicenter trial was performed to assess the feasibility and safety of delivering a pro-angiogenic transcription factor termed "hypoxia inducible factor-1alpha", delivered to ischemic cardiac muscle via a type 2 adenoviral (Ad2HIF) vector., Methods and Results: The 13 patients were included under the following criteria: 1 hypoperfused area of viable ventricular muscle without options for revascularization and left ventricular ejection fraction > or =30%. After coronary artery bypass grafting was completed, 10 injections of the study drug (n=10), in 3 escalating doses up to 1 x 10(11) viral particles or saline (n=3) as a placebo control, were injected intramyocardially. After completion of the 1-year follow-up, all patients had uncomplicated postoperative courses, are alive and feeling well; 1 patient had a self-limited run of tachycardia postoperatively and at 6 months, 1 patient developed recurrent angina. Positron emission tomography perfusion analysis revealed improvement in the Ad2HIF injected areas in selected patients., Conclusions: These data support the feasibility and preliminary safety of adenoviral transfection with Ad2HIF in regions of viable myocardium. Additional studies will be required to determine the efficacy and safety of Ad2HIF.

Introduction: Coronary artery disease progression after primary coronary artery bypass grafting may, beside classical atherosclerosis risk factors, be depending on genetic predisposition., Methods: We investigated 192 CABG patients (18% female, age: 60.9 +/- 7.4 years). Clinically cardiac adverse events were defined as need for reoperation (n = 88; 46%), reintervention (n = 58; 30%), or angina (n = 89; 46%). Mean follow-up time measured 10.1 +/- 5.1 years. Gene polymorphisms (ApoE, NOS3, LIPC, CETP, SERPINE-1, Prothrombin) were investigated separately and combined (gene risk profile)., Results: Among classical risk factors, arterial hypertension and hypercholesterinemia significantly influenced CAD progression. Single ApoE, NOS3 and LIPC polymorphisms provided limited information. Patients missing the most common ApoE epsilon 3 allele (5,2%), showed recurrent symptoms (p = 0,077) and had more frequently reintervention (p = 0,001). NOS3 a allele was associated with a significant increase for reintervention (p = 0,041) and recurrent symptoms (p = 0,042). Homozygous LIPC patients had a higher reoperation rate (p = 0.049). A gene risk profile enabled us to discriminate between faster and slower occurrence of cardiac adverse events (p = 0.0012)., Conclusion: Single APOE, LIPC and NOS3 polymorphisms permitted limited prognosis of cardiac adverse events in patients after CABG. Risk profile, in contrast, allowed for risk stratification.

Purpose: Resternotomy for aortic valve replacement in patients with previous coronary artery bypass grafting and an internal mammary artery graft may be a surgical problem. Thus, we are exploring the effect of using rapid prototyping techniques for surgical planning and intraoperative orientation during aortic valve replacement after previous coronary artery bypass grafting (CABG)., Description: As a proof of concept, we studied a patient who had undergone CABG 5 years earlier. At that time the patient received a left internal mammary artery graft to the left anterior descending artery and a venous graft to the right coronary artery. Now the patient required aortic valve replacement due to symptomatic aortic valve stenosis. The left internal mammary artery bypass and the right coronary artery bypass were patent and showed good flow in the angiography. The patient was examined by 128-slice computed tomography. The image data were visualized and reconstructed. Afterwards, a replica showing the anatomic structures was fabricated using a rapid prototyping machine., Evaluation: Using data derived from 128-slice computed tomography angiography linked to proprietary software, we were able to create three-dimensional reconstructions of the vascular anatomy after the previous CABG. The models were sterilized and taken to the operating theatre for orientation during the surgical procedure., Conclusions: Stereolithographic replicas are helpful for choosing treatment strategies in surgical planning and for intraoperative orientation during reoperations of patients with previous CABG.

Background: The magnetic vascular positioner (MVP), a device for distal bypass anastomosis in coronary surgery, was developed to allow a simple and rapid procedure and to improve graft patency. We analyze our mid-term results with this device., Methods: Eighteen distal anastomoses were performed by using the MVP, and 18 with a hand-sewn technique were completed in 11 patients. The target arteries for the MVP anastomosis were the left anterior descending in 9 patients, a marginal branch in 4, a diagonal branch in 3, and right coronary artery in 2. The left internal thoracic artery was used as graft in 9 patients, saphenous vein in 6, right internal thoracic artery in 2, and radial artery in 1., Results: Coronary angiography was performed at discharge and after a complete follow-up of 19 +/- 3.5 months. Patency at follow-up was 83.3% (15/18) for MVP anastomoses and 100% (18/18) for hand-sewn anastomoses. All occluded MVP anastomoses were performed with small-size devices. In one patient, a high-grade left main stenosis was overestimated. Competitive flow may be suspected in this case as a cause of graft occlusion. No deaths occurred during hospital stay or during follow-up. Freedom from reintervention was 100%., Conclusions: The MVP is the only mechanical connector for distal anastomoses applicable for all kind of grafts, for all coronary artery locations, and with both end-to-side and side-to-side technique. Mid-term patency of MVP anastomoses is acceptable but inferior to the patency of hand-sewn anastomoses. Occlusion of MVP supplied grafts may be produced by small device size.

Purpose: Inflammation and coagulation disturbances are common consequences of cardiopulmonary bypass (CPB). Recently, miniaturized closed CPB circuits without cardiotomy suction and venous reservoir have been proposed to reduce complication rates. We compared outcomes with conventional (CCPB) and miniaturized cardiopulmonary bypass (MCPB) after coronary artery bypass operations (CABG) with respect to inflammation and coagulation., Description: Thirty patients (23% female; aged 67.9 +/- 9.0 years) were prospectively randomly assigned to undergo isolated CABG with CCPB or MCPB. Conventional CPB had a pump prime of 1, 600 mL. Miniaturized CPB consisted of a centrifugal pump, arterial filter, heparinized tubing, and oxygenator with a priming volume of 800 mL. Shed blood was removed by a cell-saving device and reinfused. Measurements included interleukin (IL)-2 receptor, IL-6, IL-10, tumor necrosis factor receptor 55 and 75, C reactive protein, leukocyte differentiation, d-dimers, fibrinogen, and thrombocytes at six time points., Evaluation: In both groups no major complication occurred. However, two dangerous air leaks occurred in the closed MCPB circuit, demonstrating the narrow safety margins. Operative handling was also more difficult owing to limitations in venting and fluid management. International normalized ratio (p = 0.03) and antithrombin III (p = 0.04) levels were elevated during CPB in the CCPB group, most likely owing to differences of the intraoperative anticoagulation management. Repeated measures analysis revealed that not a single parameter of inflammation or clinical outcome showed significant differences among groups., Conclusions: Use of a MCPB affected inflammation and coagulation variables only marginally and did not lead to clinical relevant changes as assessed by blood loss, need for blood products, and intensive care unit and clinical stays. However, safety margins for volume loss, air emboli, and weaning from CPB decrease, because of the closed MCPB circuit.

Background: The hemodynamic and vascular effects of ventricular sourcing by a stent-based (VSTENT, Percardia) left ventricle-to-coronary artery bypass were studied in a patient subgroup of the European multicenter ADVANTAGE study (ADjunctive treatment with the VCAB/VSTENT myocardial implANT system in coronary Artery bypass Graft patiEnts)., Methods and Results: Twelve patients who underwent VSTENT implantation in addition to coronary artery bypass surgery were studied up to 12 months after the procedure. The VSTENT was implanted distal to a hemodynamically relevant coronary artery stenosis. Coronary flow velocity was assessed at rest and during dobutamine stress. Intraoperative VSTENT implantation was successful in 11 of 12 patients. Early postoperative angiograms showed patent VSTENT in 8 of 11 patients, with predominantly systolic flow distal to the VSTENT. Coronary flow velocity reserve induced by dobutamine stress was 1.7+/-0.1 (P=0.006). VSTENT patency at 2- to 6-month follow-up was present in 5 of 11 patients, with concomitant VSTENT stenosis in 4 of those 5. In all patients, coronary flow velocity increased 3- to 4-fold proximal to the VSTENT, which was associated with a moderate degree of arterial remodeling. Except for target vessel reintervention (n=5), no other major adverse events were observed in 11 of 12 patients. One patient died on the second postoperative day, though the cause was probably not related to the VSTENT implantation., Conclusions: VSTENT implantation seems to be safe in the mid-term follow-up and leads to a predominantly systolic coronary flow pattern in the vessel supplied by the VSTENT, with a flow reserve similar or close to that seen with conventional bypass. VSTENT patency rate, however, was unacceptably low at 3- to 6-month follow-up and needs to be improved.

Background: Stent-based left ventricle-to-coronary artery stent (VSTENT) is a newly developed, alternative surgical revascularization procedure (VCAB). We present here our initial experience using this technique., Methods: Twelve patients (10 male and 2 female, mean age 61 +/- 13 years) underwent a VCAB concomitant to coronary artery bypass surgery. Myocardial revascularization was performed on-pump with arrested heart in 4 patients, on-pump with beating heart in 6 patients, and off-pump in 2 patients. Average number of coronary anastomoses per patient was 2.4 +/- 0.8. In all cases left internal thoracic artery-to-left anterior descending was used. In each patient only one VSTENT was implanted. Target artery for the VCAB was a diagonal branch in 5 patients, an intermediate branch in one patient and a marginal branch in 6 patients. Mean time for the VCAB was 23 +/- 5 minutes (17 to 30 minutes)., Results: An immediate procedural success was observed in 11 of 12 cases. In one case VCAB was not successful and conventional aortocoronary bypass was performed. One patient died on the second postoperative day due to a systemic inflammatory response syndrome. Autopsy demonstrated a patent VSTENT. Angiography was performed in 10 patients 2 to 16 days (9 +/- 5 days) postoperatively showing a patent VSTENT in 8 patients., Conclusions: The VCAB was feasible and potentially safe in the short-term postoperative follow-up, particularly with increasing experience after the first patients. Though the VSTENT is a promising tool for myocardial revascularization, long-term safety, patency, and performance of the device needs to be determined.

Little is known concerning the natural history of psychiatric morbidity, postoperative delirium, cognitive decline and health-related quality of life (HRQOL) in cardiac surgery patients and the impact of neurocognitive dysfunction on HRQOL after cardiac surgery with cardiopulmonary bypass (CPB). In a prospective study, we followed up for 1 year 30 of the original 34 patients who had undergone cardiac surgery with CPB. Patients were assessed preoperatively, before discharge, and at 1 year after surgery with the Structural Clinical Interview for DSM-IV and a series of neuropsychological tests. Psychometric scales were administered to evaluate cognitive functioning (Syndrom Kurztest), depressive symptomatology (Montgomery-Asberg Depression Rating Scale), posttraumatic stress symptoms (Posttraumatic Stress Syndrome 10-Questions Inventory) and HRQOL (SF-36 Health Status Questionnaire). Delirium Rating Scale (DRS) was used daily over the course of intensive care unit treatment. Postoperative delirium developed in 11 of the 34 patients (mean DRS rating scale score+/-S.D.: 20.36+/-6.22, range: 14-31). Short-term consequences of cardiac surgery included adjustment disorder with depressed features (n=11), posttraumatic stress disorder (n=6), major depression (n=6) and clinically relevant cognitive deficits (n=13). At 12 months, the severity of depression and anxiety disorders improved and returned to the preoperative level, and 6 out of the 30 followed-up patients displayed cognitive deficits. Our patients' HRQOL SF-36 self-reports significantly improved compared with baseline quality of life data. However, 1-year overall lower cognitive function scores were associated with lower HRQOL. Cardiac surgery with CPB is associated with improvements in HRQOL relative to the preoperative period, but the presence of cardiac surgery-related cognitive decline impairing HRQOL is a complication for a subgroup of cardiac surgical patients in the long-term outcome.

The objective of this study was to assess event-free survival and total treatment costs of retroinfusion-supported stenting in high-risk patients compared to bypass surgery. An increasing number of patients with main-stem and main-stem-equivalent stenosis are treated by stent implantation, which appears to be safe in the short-term follow-up. However, there is a lack of randomized studies comparing conventional bypass surgery with stent implantation, particularly in patients with high risk for both treatments. We here report on the 1-year results of a prospective randomized single-center study in patients with symptomatic main-stem and main-stem-equivalent lesions with substantially increased risk for bypass surgery. Patients where randomized to undergo either percutaneous transluminal coronary angioplasty/stent procedure (n = 23) or bypass surgery (n = 21). Patients randomized to stent implantation were supported by selective pressure-regulated retroinfusion of the anterior cardiac vein during ischemia. Patients of the stent group and the bypass group did not differ in baseline characteristics, including Parsonnet score and quality-of-life score. Twenty-eight-day mortality and 1-year mortality rate as well as quality-of-life scores were similar in both groups. Event-free survival after 1 year was higher in the bypass group (71.4% vs. 52.3%; P = 0.02) due to a lower target lesion revascularization rate. With regard to total treatment costs, however, the stent group compared favorably to the bypass group (9,346 +/- 807 vs. 26,874 +/- 3,985 euro), predominantly as a result of a shorter intensive care and hospital stay. In this first randomized study in high-risk patients for stent implantation and bypass surgery, patients with retroinfusion-supported stent implantation had a similar 1-year outcome and quality of life compared to patients with bypass surgery. Though in the stent group event-free survival was lower and target lesion revascularization rate was higher, retroinfusion-supported stent implantation was associated with substantially lower costs and might be considered as an alternative treatment option in this selected group of high-risk patients., (Copyright 2004 Wiley-Liss, Inc.)

Stent-based ventricle-to-coronary artery bypass (VSTENT) has been shown experimentally to provide systolic instead of physiological diastolic blood flow directly from the left ventricle to a coronary artery distal to a high-grade stenosis. We report on the first successful surgical implantation of a VSTENT in a patient with coronary artery disease. At 3-month follow-up, the VSTENT was patent and showed sufficient regional blood flow at rest with a significant flow reserve. In addition, the patient was asymptomatic during exercise testing. Though encouraging, these observations have to be confirmed and are the subject of an ongoing multicenter study., (Copyright 2004 Wiley-Liss, Inc.)

Background: We present our early and midterm results with off-pump coronary artery bypass grafting (OPCAB) on the beating heart and with conventional coronary artery bypass grafting (CABG) and compare patient outcomes for both procedures., Methods: Between November 1997 and April 2001, OPCAB was performed in 330 patients. The results were compared with those of a matched population of 330 patients who had undergone CABG during the same period. Specific postoperative outcomes were evaluated for patient subgroups with multimorbidity, with impaired ventricular function, of an older age, and of a young age without comorbidities. Midterm results and quality-of-life (QOL) scores for patients were obtained by follow-up., Results: In the overall series, OPCAB resulted in signifi- cantly shorter surgery times (P =.008), ventilation times (P <.001), intensive care unit (ICU) stays (P <.001), and hospital stays (P =.006). OPCAB also resulted in less postoperative inotropic medication (P =.041), lower transfusion rates (P <.001), fewer postoperative myocardial infarctions (P =.038), and lower hospital mortality rates (P =.024). Among the patient subgroups, patients with multimorbidities were the only subgroup to show a significant reduction in hospital mortality after OPCAB surgery (P =.048). Times of postoperative ventilation, ICU stay, and hospitalization were significantly reduced for all patient subgroups (P <.05). After mean followup times of 43.8 months (OPCAB) and 44.8 months (CABG), QOL scores, midterm complication rates, and mortality rates were not significantly different among the groups., Conclusion: OPCAB surgery improved postoperative recovery for the entire patient population without compromising midterm outcome. Compared with conventional CABG, high-risk patients with multimorbidity particularly profit from avoiding cardiopulmonary bypass and show significantly lower hospital mortality.

Background: Off-pump cardiac surgery is becoming an established method of surgical revascularization. However, performing anastomoses on a beating heart can be challenging, especially through small incisions. We compared our midterm results in patients with 1 vessel disease using full sternotomy (OPCAB) or a left anterior minithoracotomy (MIDCAB)., Methods: At our institution between December 1996 and December 1998, 102 patients (OPCAB, n = 45, MIDCAB, n = 57); age, 61 +/- 11 years; 69% men with 1-vessel disease of the left anterior descending coronary artery (LAD) underwent off-pump myocardial revascularization through the left internal thoracic artery (LITA). In the OPCAB group 17 (37.8%) of the patients received an additional vein graft to a diagonal branch. OPCAB was generally preferred in obese or high-risk patients or patients with a long LITA-LAD distance (>7 cm) on an electron beam computed tomography of the chest., Results: Operative mortality was 0. Time of surgery (169 +/- 48 versus 197 +/- 45 minutes) and coronary artery occlusion time (19 +/- 7 versus 23 +/- 6 minutes) were significantly lower (P = .004 and P = .009) in the OPCAB group. MIDCAB surgery was related to a higher incidence of occluded (4 versus 0; P = .039) or stenosed (7 versus 2; P = .06) anastomoses and necessity for immediate reintervention (9 versus 0; P = .023). During a mean follow-up period of 5.2 years, MIDCAB patients (6 MIDCAB patients versus 1 OPCAB patient) tended to need more coronary interventions and develop more recurrent angina (23 MIDCAB versus 12 OPCAB patients). Two OPCAB patients died during the follow-up period., Conclusions: Our initial experience in beating heart surgery demonstrated that MIDCAB is technically more challenging than OPCAB. MIDCAB procedures should therefore be performed by experienced surgeons on selected patients. Midterm results after OPCAB procedures tend to a lower rate of adverse cardiac events.

Background: This study was designed to evaluate the efficacy of two different stabilizer concepts for off-pump coronary artery bypass grafting., Methods: Between 2000 and 2001, 100 consecutive patients who underwent off-pump coronary artery bypass grafting were randomly assigned to two stabilization systems: the Medtronic Octopus 3 (n = 50) and the Genzyme Immobilizer (n = 50). During operation, two-dimensional cardiac surface motion was assessed by intravital microscopy using orthogonal polarization spectral imaging in 20 vessels at the anterior wall. Postoperative angiography of 47 vessels revealed anastomotic quality., Results: Patient demographics were similar in both groups regarding age, sex, ejection fraction, and New York Heart Association functional class. In 7 patients the randomized Immobilizer was rejected by the surgeon for lateral or posterior wall revascularization and subsequently switched to the Octopus device. Patients received 1.8 +/- 0.7 grafts in the Octopus and 1.6 +/- 0.5 in the Immobilizer group (p = not significant). Two-dimensional cardiac surface motion was significantly less using the Immobilizer (109.7 +/- 32.4 microm versus 423.5 +/- 129.6 microm; p < 0.001). Time required for anastomosis was significantly shorter in the Immobilizer group (11.3 +/- 3.5 versus 14.9 +/- 2.4 minutes; p < 0.001). Postoperative angiography showed no vessel occlusions but two anastomotic stenoses in each group., Conclusions: Both stabilizers have been shown useful for off-pump coronary artery bypass grafting. The Immobilizer system showed better epicardial immobilization of the anterior wall resulting in shorter anastomosis times. However, because the Octopus 3 handling is more flexible and allows easier access to all vessels, it is the device of choice for posterior wall revascularization in our institution.

Background: Recently, the ZEUS(tm) Robotic Surgical System has been introduced to increase the precision of endoscopic cardiac surgery. This study investigated its clinical use for endoscopic coronary artery bypass grafting., Material/methods: Between 1998 and 2001, 41 patients with single and multivessel disease were operated on using the ZEUS(tm) system. The robotic system was introduced step by step into clinical practice. Initially, the system was used only for endoscopic internal mammary artery (IMA) harvest (n=12), later for coronary anastomoses on the arrested (n=13) or beating heart after median sternotomy (n=6), and finally for endoscopic coronary bypass grafting on either the arrested (n=2) or beating heart (n=8)., Results: Endoscopic IMA harvest ranged from 48 to 110 min and was completed in all cases. In the sternotomy group, the robotic anastomosis time averaged 21 min on the arrested and 25 min on the beating heart, respectively (n.s.). In the endoscopic cases, the average time for endoscopic anastomosis was 41 min on the arrested and 36.5 min on the beating heart (n.s.), with an overall duration of surgery between 4.0 and 8.0 hours. One endoscopic case was intraoperatively converted to a MIDCAB procedure with manual anastomosis. The total patency rate of all graft anastomoses, confirmed by early postoperative angiographic control, was 97%. One patient underwent reoperation with an uneventful postoperative course., Conclusions: The present study demonstrates the feasibility of endoscopic coronary revascularization using a computer-assisted surgical robotic system on the arrested and beating heart in selected patients.

Objective: Coronary bypass surgery can be performed less invasively by avoiding cardiopulmonary bypass (CPB). We present our experiences with beating heart bypass surgery performed through a minithoracotomy or sternotomy., Methods: From May 1997 to September 1999, 340 patients were included in a prospective study. Of these patients, 111 (group 1) underwent minimally invasive direct coronary artery bypass grafting (MIDCAB) through an antero-lateral minithoracotomy, and 229 (group 2) had off-pump coronary artery bypass grafting (OPCAB) through a full sternotomy. A pressure stabilizer was used for MIDCAB and a suction stabilizer for OPCAB surgery. Early postoperative angiography was performed on 48% of patients in group 1 and 45% of those in group 2. Statistical analysis was applied to compare the variables from both groups and a probability value of less than 0.05 was considered significant., Results: In all MIDCAB grafts, revascularization was performed by a single left internal mammary artery (LIMA) graft to the left anterior descending coronary artery (LAD). This procedure was completed in 96.4% of patients without CPB. Conversion to sternotomy was necessary for one patient (0.9%). In the OPCAB group, an average of 1.7 grafts per patient were revascularized, of which 98 were single, 99 double, and 32 triple. Of the OPCAB group, 12% of patients were redo operations and 17% had severe comorbidities. Conversion to CPB was necessary for 10 patients (4.4%) because of hemodynamic instability. No cerebrovascular accident (CVA) was seen in any group. There were no hospital deaths in the MIDCAB group, but there were three deaths (1.3%) in the OPCAB group. Age, previous bypass surgery, and severe comorbidities did not influence early mortality. Early postoperative reoperation due to graft failure was necessary for three patients (2.7%) after MIDCAB and for three patients (1.3%) after OPCAB. Confirmed by angiography, the early postoperative total graft patency rate was 96.2% in the MIDCAB group and 96.6% in the OPCAB group; the perfect patency rate (no stenosis greater than 50%) was 92.4% and 93.1%, respectively., Conclusions: Coronary bypass surgery without the use of CPB is feasible and safe, and offers good early results. Nevertheless, MIDCAB grafting is a challenging technique and should only be performed in selected patients with favorable coronary anatomy. On the other hand, with the sternotomy approach, exposure of all vessels was well tolerated and made complete revascularization feasible. OPCAB can be performed safely even on high-risk patients.

Introduction: The use of extracorporeal circulation (ECC) during coronary artery bypass graft (CABG) surgery is associated with a systemic inflammatory response due to the contact of blood with artificial surfaces. The clinical relevance of ECC-related systemic inflammation varies with the patient, and such inflammation may be accompanied by intermittent organ dysfunction and an increased catecholamine requirement. We investigated the effects of a new phospholipid coating system of ECC on systemic inflammatory response and clinical outcome following CABG., Methods: Patients scheduled for CABG surgery were prospectively divided randomly into 2 patient groups: patients using noncoated ECC materials and patients using phospholipid-coated ECC materials. Clinical data measured perioperatively included hemodynamics, aortic clamp time, duration of bypass, time to extubation, catecholamine requirement, length of intensive care unit (ICU) stay, postoperative blood loss, and amount of blood transfused. In addition, blood samples were collected before cannulation and at 2, 24, and 48 hours postoperative. Cytokines (tumor necrosis factor alpha [TNF-alpha] and interleukin 10 [IL-10]) and P-selectin were measured with an enzyme-linked immunosorbent assay. Plasma nitrate/nitrite levels (NOx) were determined by the Griess reaction., Results: A significant increase of TNF-a level was noted in the uncoated control group only. In the uncoated group, IL-10 levels significantly increased at 2 hours postoperative, whereas levels remained unchanged in the phospholipid coating group. P-selectin increased 2 hours postoperative in the uncoated group, and no significant changes were noted in the phospholipid coating group. At 24 hours postoperative, total plasma NOx production significantly increased in the phospholipid coating group but remained constant in the control group. No significant differences with respect to postoperative parameters (time to extubation, ICU stay, amount of bleeding, blood transfused, and catecholamine requirement) were observed., Conclusions: Phospholipid coating significantly reduces the systemic increase in proinflammatory and anti-inflammatory cytokines and P-selectin. Despite the comparable clinical outcomes in this study, the observed significant reduction in systemic inflammatory parameter values suggests an improved biocompatibility of ECC materials when they are coated with phospholipids.

Background: There is concern that the technical limitations of robotic systems used in endoscopic coronary artery bypass grafting (CABG) may lead to increased trauma of the anastomotic site. To examine this issue, we compared the acute traumatic changes of the coronary artery wall caused by conventional manual suturing and robotically assisted suturing for anastomoses using the ZEUS telemanipulator (Computer Motion Inc., Goleta, CA) in a laboratory setting., Methods: Coronary artery bypass grafting was performed on isolated porcine hearts. Fifteen anastomoses (with harvested porcine right coronary artery (RCA) segments) were carried out using the ZEUS microsurgical telemanipulator (group Z), while 15 further anastomoses were performed with a conventional manual technique (group M) using Gore-Tex CV-8 suture material. Specimens were taken from each anastomotic site and from native parts of the left anterior descending artery (LAD) (control group). Morphological changes of the cellular and fibrous components of the lamina intima and lamina media, and the shape and maximum diameter of the puncture mark, were examined by light microscopy (LM), transmission electron microscopy (TEM), and scanning electron microscopy (SEM). Vascular endothelial damage and denudation were graded on a score from 1 to 5., Results: In each group, 14 specimens were evaluated. SEM findings showed a significantly higher degree of endothelial denudation in group Z and group M compared to the control group, while group Z was significantly more affected than group M. Likewise, the maximum diameter of the puncture mark was significantly larger in group Z than in group M. TEM and LM studies supported these results. In addition, LM revealed that in five specimens of group Z the shape of the stitch through the artery wall was not cylindrical, as in the other cases, but was asymmetrical and displayed a superficial furrow on the side of the vascular lumen., Conclusion: The results indicate that there is an increased incidence of damage to the coronary artery wall caused by the microsurgical telemanipulator. Further studies are necessary to determine whether the differences between conventional and robotic-assisted suturing techniques will have an effect on the long-term outcome of coronary artery bypass grafting.

Background: Intraoperative graft patency verification is of major clinical importance for quality control after coronary artery bypass grafting (CABG), especially if surgery is performed on the beating heart. This is one of the first reports of fluorescence coronary angiography (FCA) using the dye indocyanine green (ICG), a noninvasive technology for direct visualization of coronary arteries, bypass grafts, and myocardial perfusion., Methods: Twenty-three domestic pigs (weight, 45-72 kg) underwent FCA of the left anterior descending coronary artery (LAD). In the first group (n = 6 pigs), FCA was used to visualize the native coronary vessels and myocardial perfusion. In the second group (n = 8 pigs), 14 stenoses of various degrees and 4 total vessel occlusions were created by snares on different segments of the LAD, and FCA was used to visualize the effects of these obstructions. In the third group (n = 9 pigs), a coronary bypass procedure on the beating heart was performed by a left internal mammary artery or a human saphenous vein graft to the LAD, and FCA was used to visualize graft patency. Three pigs were removed from the study because of ventricular fibrillation. ICG was intravenously applied, and the heart was illuminated with near-infrared light emitted by laser diodes. The fluorescence emission was detected by an adapted charge-coupled device camera system. The images were displayed in real time on a high-resolution monitor. Subsequently, images obtained with FCA were compared to those obtained with coronary angiography (n = 10 pigs)., Results: In all cases, high-quality FCA images of coronary arteries and myocardial perfusion were obtained. All stenoses resulted in an impairment of the myocardial perfusion visualized by FCA. Occlusion of the LAD or the diagonal branch resulted in a total perfusion defect of the corresponding anterior myocardial wall with immediate reperfusion after releasing the snare. In 5 cases a patent bypass graft with an apparent homogenous perfusion of the corresponding myocardium was detectable. In one procedure, FCA images indicated total occlusion of the bypass graft and a total perfusion deficit in the distal LAD region. Correlation between FCA and coronary angiography in detection of stenoses and graft patency was excellent., Conclusion: With the fluorescence technique using ICG, visualization of blood flow in coronary vessels and bypass grafts, as well as of myocardial perfusion, is feasible. FCA is a highly sensitive and reproducible method and an excellent technique for intraoperative quality control in CABG.

Left atrial intramural hematoma is a seldom cause of left atrial mass. It has been described to occur spontaneously, after interventional procedures, after blunt chest trauma, or after aortocoronary bypass surgery. We present a case of mitral valve replacement together with the removal of a large intraatrial space-occupying lesion. Intraoperative transesophageal echocardiography confirmed a successful resection of this mass. Surprisingly, upon admission to ICU, transesophageal and transthoracic echocardiography revealed a recurrence of an intramural lesion, closest matching a hematoma, which was confirmed by contrast-enhanced computed tomography. Surgical intervention was thoroughly discussed but a conservative management was favoured. 3 months after surgery, a reassessed transthoracic echocardiography and computed tomography demonstrated an almost complete resolution of the pre-existing hematoma. [ABSTRACT FROM AUTHOR]

The glycoprotein IIb/IIIa (GP IIb/IIIa) receptor antagonists prevent platelet aggregation and thrombus formation, improving outcomes of patients with acute coronary syndrome. Therapy with these agents may lead to bleeding complications and thrombocytopenia, challenging the perioperative management of patients undergoing coronary surgery. We report the successful management of an acute profound thrombocytopenia after urgent off-pump coronary surgery in a patient treated with tirofiban for unstable angina and acute coronary syndrome. [Copyright &y& Elsevier]

Rapid developments in interventional cardiology for the treatment of coronary artery disease ask for further evolution of surgical revascularization techniques with improved short-term and long-term results. Off-pump bypass grafting, total arterial revascularization, and use of composite arterial grafts are innovative operative procedures that are already established in many centers. We describe our technique to combine all three procedures in a single operation. [Copyright &y& Elsevier]

Aortic recoarctation may be difficult to manage, especially in patients with the need for additional surgical interventions. We describe the case of a 45-year-old man with grown-up congenital heart disease, presenting with recoarctation after initial anatomic repair with a prosthetic graft at the age of 16 years. Further examination revealed heart failure and left ventricular dilation because of severe aortic regurgitation, owing to a bicuspid aortic valve. Through a median sternotomy and CPB, an aortic valve replacement and extra-anatomic ascending-to-descending aortic-bypass-grafting was performed with a posterior pericardial approach. Off-pump coronary artery bypass techniques were applied to reach the descending aorta. [Copyright &y& Elsevier]

Abstract: Objective: Fibrin sealants are frequently used in aortocoronary bypass operations. Although they are considered to be clinically safe, we performed a retrospective analysis of our data to examine the possible side effects of Tissucol® fibrin sealant, namely the acute thrombosis of grafts and native coronary arteries resulting in severe myocardial damage and patient deaths. Methods: The data of 2716 patients (2001 male, 715 female) who received an aortocoronary bypass operation from November 1995 to December 1999 were studied retrospectively. Two groups (group 1: received Tissucol®, group 2: no sealant used) were compared with respect to an a priori selected set of demographic and clinical variables and with respect to their effect on the outcome using bivariate tabulation. Multiple exploratory assessments of factors possibly related to fatal outcome were done by multiple logistic regression. Results: Nine hundred ninety patients (group 1) received Tissucol®, 1726 patients (group 2) did not receive it. Mean patient age was 64±9.1 years. Group 1 had a higher risk of death (7.8% vs 2.8%, p <0.001). The peak values of creatine kinase >500 and creatine kinase-myocardial band >50 were higher in group 1 than in group 2, p <0.001. Adjusted odds ratios for the risk of fatal outcome were: 2.01 for the use of Tissucol®, 2.71 for patient age >70 years, 2.02 for aortic cross clamp time >90min, 3.95 for postoperative ventricular fibrillation, 6.35 for postoperative cardiopulmonary resuscitation, 4.55 for postoperative aortocoronary reoperation. Conclusion: In our analysis an increased risk of myocardial injury or even death was found in coronary artery bypass grafting patients when Tissucol® fibrin sealant was used intraoperatively. [Copyright &y& Elsevier]