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Objective. We sought to evaluate if patients with proximal critical circumflex (CX) lesions did better with single SV-CABG on the best obtuse marginal (OM), or with sequential SV-CABG on two OM branches. Design. Ninety patients were prospectively randomised to single SV-CABG on the best OM (sSV-CABG-45 patients; Group A) or to sequential SV-CABG on 2 OM (seqSV-CABG 45 patients; Group B). Transit-time flowmetry (TTF), and graft flow reserve were evaluated. Recurrent angina, acute myocardial infarction, readmission for coronary reintervention were defined "treatment failure" during follow-up. Results. SeqSV-CABG showed better intraoperative maximum (119.1±57.5 ml/min vs. sSV-CABG 62.4±29.6; p=0.001), mean (56.3±31.5 ml/min vs. 30.8±12.8; p=0.0001), minimum flow (22.8±9.2 ml/min vs. 11.8±8.9; p=0.001) and P.I. (0.71±0.4 vs.1.46±0.9; p=0.006). Graft flow reserve also proved to be higher (95.4±29.7 ml/min mean flow vs. sSV-CABG 42.3±15.2 ml/min mean flow; p=0.0001; flow reserve 1.72±0.99 vs 1.32±1.09; p=0.001) as well as freedom from treatment failure (97.5±0.5% vs 88.7±0.4%; p=0.05). Conclusions. SeqSV-CABG showed higher TTF flows, with no incremental risk for perioperative morbidity. Higher flows and graft flow reserve may allow lower treatment failure at mid-term follow-up. [ABSTRACT FROM AUTHOR]

Coronary arteriovenous fistulas (CAVF) are rare malformations. Opinions vary on which operation should be offered to these patients, particularly those asymptomatic. We report four patients operated on for CAVF referred to our institution over the course of a year. Three patients had associated cardiac lesions. In all of them CAVF was identified and closed with running sutures. There was no operative mortality or operative morbidity. All patients were asymptomatic at follow-up. In patients undergoing surgical treatment of cardiac disease, associated CAVF should always be treated. Although in patients with giant CAVF it is safer to patch the outflow of CAVF from the outflow chamber, in the majority of cases CAVF should be identified intraoperatively and closed with multiple running stitches. [ABSTRACT FROM AUTHOR]

Background: Linear flow during cardiopulmonary bypass is considered a potential mechanism of lung damage in patients with chronic obstructive pulmonary disease (COPD). We evaluated differences in lung function of patients with COPD undergoing preoperative intraaortic balloon pumping (IABP), between linear flow during cardiopulmonary bypass (IABP-off) and maintenance of pulsatile flow (IABP-on at automatic 80 bpm) during cardioplegic arrest. Methods: Fifty patients with COPD undergoing preoperative IABP were randomized between January 2004 and July 2005 to receive nonpulsatile cardiopulmonary bypass with IABP discontinued during cardioplegic arrest (25 patients; group A), or IABP-induced pulsatile cardiopulmonary bypass (25 patients; group B). Hospital outcome, need for noninvasive ventilation, oxygenation (partial pressure of oxygen, arterial to fraction of inspired oxygen [Pao 2/Fio 2]), respiratory system compliance, and scoring of chest radiographs were compared. Results: There were no hospital deaths, no IABP-related complications, and no differences in postoperative noninvasive ventilation (group A: 6 of 25, 24.0% vs group B: 5 of 25, 20%; p = not significant [NS]). One patient in both groups developed pneumonia (p = NS). Intensive care and hospital stay were comparable (p = NS). Group B showed lower intubation time (8.3 ± 5.1 hours versus group A: 13.2 ± 6.0; p = 0.001), better Pao 2/Fio 2 at aortic declamping (369.5 ± 93.7 mm Hg vs 225.7 ± 99.3; p = 0.001) at admission in intensive care (321.3 ± 96.9 vs 246.2 ± 109.7; p = 0.003), and at 24 hours (349.8 ± 100.4 vs 240.8 ± 77.3; p = 0.003). The respiratory system compliance was better in group B at the end of surgery (56.4 ± 8.2 mL/cm H2O vs 49.4 ± 7.0; p = 0.004) and 8 hours postoperatively (76.4 ± 8.2 vs 59.4 ± 7.0; p = 0.0001), as well as scoring of chest radiograph at intensive care admission (0.20 ± 0.41 vs 0.38 ± 0.56; p = 0.05) and on the first day (0.26 ± 0.45 vs 0.50 ± 0.67; p = 0.025). Conclusions: Automatic 80 bpm IABP during cardioplegic arrest preserves lung function in patients with COPD. [Copyright &y& Elsevier]

Background: Myocardial infarction remains a devastating complication after coronary revascularization. Although electrocardiography (ECG) and echocardiography suggest transmural infarction, myocardial damage and the quality of myocardial protection are not recognized unless troponin I (TnI) is assessed. Determinants and prognosis of TnI elevation after coronary artery bypass grafting (CABG) were evaluated. Methods: Data of 776 consecutive patients undergoing CABG between January 2002 and January 2004 were prospectively exposed to univariate and multivariate analysis. We evaluated the prognosis of patients with all the ECG, echocardiographic, and biochemical criteria for acute myocardial infarction and that of patients with only TnI elevation. Twelve-month follow-up survival and freedom from cardiac events (FCE) were accomplished. Results: Troponin I greater than 3.1 μg/L at 12 hours was detected in 6.9% of the population, and correlated with lower in-hospital (p < 0.001) and follow-up survival (p = 0.00001), and lower FCE (p = 0.0009). Twenty-one (38.8%) of these fulfilled ECG-echocardiographic criteria (p = 0.05), demonstrating higher TnI values at 12 (p = 0.001), 24 (p = 0.01), 48 (p = 0.01), and 72 (p = 0.04) hours, prolonged ventilation time (p = 0.001), higher in hospital mortality (p = 0.003), lower follow-up survival (p = 0.023), and lower FCE (p = 0.0084). A EuroSCORE greater than 6, ongoing unstable angina, aortic cross-clamp time greater than 90 minutes, cardiopulmonary bypass time greater than 180 minutes, incomplete revascularization, and intraoperative intraaortic balloon pump were independent predictors of myocardial damage (MD) at multivariate analysis. Combined antegrade and retrograde cardioplegia and postoperative enoximone infusion were associated with a lower TnI elevation. Conclusions: Troponin I greater than 3.1 μg/L at 12 hours defines perioperative MD. Associated ECG-echocardiographic criteria indicate acute myocardial infarction and anticipate a worse outcome. Identification of predictors for MD is important to develop preventative strategies, as antegrade plus retrograde cardioplegia and enoximone infusion. [Copyright &y& Elsevier]