Search

Objective: Patients with bicuspid aortic valves can present with aortic insufficiency caused by cusp disease or the aortic root pathology. We present our 13-year experience with a functional and systematic approach to bicuspid aortic valve repair., Methods: Between 1995 and 2008, 122 consecutive patients (mean age, 44 +/- 11 years) with bicuspid aortic valves underwent non-emergency valve repair for isolated aortic insufficiency (43%), aortic root dilatation (14%), or both (43%). Preoperative echocardiography identified aortic dilatation (n = 75), cusp prolapse (n = 96), and cusp restriction (n = 45) as mechanisms of aortic insufficiency. Raphé repair (n = 98) was performed by shaving (21%) or resection with primary closure (60%) or pericardial patch (18%). Functional aortic annuloplasty was performed using subcommissural annuloplasty (n = 51), ascending aortic replacement (n = 17), or aortic root replacement (n = 54) using a reimplantation (76%) or remodeling technique (24%)., Results: There was no operative mortality. Five patients underwent early aortic valve reoperation (3 re-repairs). At discharge, 93% of patients had aortic insufficiency grade 0/1 and 7% of patients had grade 2. Seven additional patients underwent aortic valve reoperation during follow-up (2 re-repairs). Overall survival was 97% +/- 3% at 8 years. At 5 and 8 years follow-up, freedom from aortic valve reoperation was 94% +/- 2% and 83% +/- 5%, respectively, and freedom from aortic valve replacement was 96% +/- 2% and 90% +/- 5%, respectively. Freedom from recurrent aortic insufficiency (>2+) was 94% +/- 3% at 5 years. Freedom from thromboembolism and bleeding was 96% +/- 2% at 8 years., Conclusion: A systematic approach to bicuspid aortic valve repair yields good early and midterm results. Repair of bicuspid valves for aortic insufficiency is a feasible and attractive alternative to mechanical valve replacement in young patients., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Transapical aortic valve implantation requires puncture of the left ventricle apex and insertion of a 32-French delivery sheath. A critical step in the procedure consists of secure closure of the ventricular apex. We describe 2 cases of apical rupture of 42 transapical aortic valve implantations. Furthermore, we describe the use of a newly designed single circular Teflon pledget that can help to avoid this complication. This pledget provides a more secure and uniform shrinkage of the entire apex to close the defect left by the delivery sheath.

Objective: : Bypass surgery and percutaneous coronary interventions improve the clinical status of patients with left anterior descending coronary artery disease. However, these techniques differ in invasiveness and in the need for subsequent reinterventions. The development of minimally invasive direct coronary artery bypass (MIDCAB) surgery and of drug-eluting stents (DES) offers perspectives to close this gap., Methods: : We compared the long-term clinical outcome of 308 patients after revascularization for isolated left anterior descending coronary artery disease. One hundred fifty-four patients were treated with MIDCAB and 154 with percutaneous coronary interventions and DES implantation., Results: : Both groups were similar in age (63 ± 13 and 62 ± 10 years), Euroscore (3.3 ± 2.8 and 3.4 ± 2.6), and mean duration of follow-up (30 ± 17 and 24 ± 10 months). Two-year survival was similar after MIDCAB and after DES (97.4% and 94.8%). During follow-up, four patients (2.6%) of the MIDCAB group and 21 patients (13.6%) of the DES group needed subsequent revascularization of the target vessel (P = 0.001). Revascularization of a nontarget vessel was needed in 11 patients (7%) of the MIDCAB group and in 17 patients (11%) of the DES group (NS). Neurologic complications included two transient ischemic accidents and two strokes in the MIDCAB group but three fatal cerebral hemorrhages and one stroke in the DES group. Major adverse coronary and cerebrovascular events rates were 14% in the MIDCAB and 31% in the DES group., Conclusions: : MIDCAB and DES implantation showed similar rates of mortality but a higher reintervention rate after DES. Anticoagulation implications remain critical for the future of DES.

Background: The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery., Methods and Results: Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade > or =3+) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI < or =2+ and in 57% of those with AI > or =3+ (P=0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, P<0.001). Overall survival at 8 years was 88+/-8%. Freedom from AV reoperation at 8 years was similar with preoperative AI < or =2+ versus preoperative AI > or =3+ (89+/-11% versus 90+/-7%, P=0.7) and with versus without cusp repair (84+/-17% versus 92+/-8%, P=0.5). Freedom from recurrent AI (grade > or =3+) at 5 years was also similar between groups (90+/-10% versus 89+/-8%, P=0.9, and 90+/-8% versus 89+/-9%, P=0.8, respectively). By multivariate analyses, predictors of recurrent AI > or =2+ were preoperative left ventricle end-diastolic diameter and AI >1+ on discharge echocardiography., Conclusions: With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair.

Background: Cusp prolapse management is important in aortic valve (AV) sparing and repair to achieve durable results. We analyzed the midterm outcomes of two different techniques for trileaflet AV prolapse repair., Methods: Between 1996 and 2008, 376 patients underwent elective AV repair: 88 with trileaflet AV (23%) had cusp prolapse repair, plication technique was performed in 34 (39%), resuspension technique in 33 (37%) and plication plus resuspension in 21 (24%). One cusp was repaired in 55 (62%), 2 cusps in 18 (21%), and 3 cusps in 15 (17%)., Results: No hospital deaths occurred. Patients undergoing resuspension with or without plication had more preoperative aortic insufficiency (AI; p = 0.01) and multiple cusp prolapses (p = 0.01). During follow-up (median, 41 months), 4 deaths occurred and 2 were cardiac related. Overall survival at 5 years was 95% +/- 5%. Two patients needed AV reoperation because of recurrent AI or AI plus AV stenosis. Recurrent AI grade > or =3+ developed in 4 patients; 1 with moderate AV stenosis. Freedom from reoperation at 5 years was 100% for plication, 96% +/- 4% for resuspension, and 93% +/- 7% for plication plus resuspension (p = 0.6); respective freedom from AI > or =3+ at 3 years was 100%, 92% +/- 8%, and 89% +/- 11% (p = 0.8)., Conclusions: Cusp plication or resuspension are efficient and durable techniques to correct cusp prolapse in the trileaflet AV. Plication is typically the first choice because of its ease of use and lower risk of overcorrection; however, free margin resuspension is useful in specific situations.

Objective: Y-graft configuration with left and right ITA (RITA) allows complete arterial revascularisation. We previously compared two types of ITA revascularisation in a prospective randomised trial with a systematic 6-month angiographic follow-up study. The present study is a secondary analysis of these populations to evaluate the angiographic parameters influencing the function of the RITA used in a Y-graft configuration., Methods: The functionality of the RITA was based on the TIMI grade flow: in TIMI grade 0 (occluded graft) and in TIMI grade 1 or 2 (balanced flow), the RITA was considered not functional. RITA was considered functional when a complete opacification (TIMI 3) of all anastomoses of the targeted coronary vessels was observed., Results: A total of 25.3% of RITA were not functional. In univariate analysis, the number of anastomoses, the type and size of grafted coronary segments and the severity of the native coronary stenosis influenced ITA function. In multivariate analysis, the function of the RITA was positively influenced by the number of anastomoses (OR=0.5, 95% CI: 0.4-0.7), and a severely narrowed first circumflex (OR=39.1, CI: 8.1-189.2) and negatively by the presence of a grafted intermediate coronary artery (OR=0.01, CI: 0.003-0.06), and of a grafted RCA (OR=0.08, CI: 0.02-0.35). The size of targeted vessel, history of infarction and regional myocardial function did not influence ITA function., Conclusions: In this systematic angiographic study, the function of the RITA used as a Y-graft was significantly improved when used on several branches of the circumflex artery or on a severely narrowed first circumflex. Grafting of the intermediate branch or of a RCA has a negative prognostic influence on graft function.

Background: Repair of rheumatic mitral valves has met with limited success because hemodynamic obstruction may persist after repair because of residual diseased leaflet tissue and lack of suppleness. Over the past decade, we have developed and implemented an aggressive approach to rheumatic mitral valve repair with radical excision of the diseased leaflets area, and subvalvular apparatus and subsequent reconstruction, with the objective of removing all diseased valvular tissue., Methods: From July 1996 to June 2007, 78 patients underwent mitral valve repair for rheumatic valve disease. Over the same time interval, 54 patients underwent mitral valve replacement. Mean age was 56.4 +/- 16 years. Clinical follow-up (mean 60 +/- 36 months) was complete in 100% of patients, and echocardiographic follow-up (mean 52 +/- 37 months) was 96% complete., Results: There was no hospital mortality or early reoperations. Overall survival was 94% +/- 6% at 8 years, and 95% of patients were in New York Heart Association functional class II or less. Three patients (4%) required reoperation for mitral restenosis and 2 underwent re-repair. At 8 years of follow-up, freedom from cardiac death and mitral valve reoperation were 98% +/- 2% and 94% +/- 5%, respectively. Freedom from valve-related events at 5 and 10 years was 90% +/- 8% and 86% +/- 11%, and freedom from significant mitral regurgitation was 98% +/- 2% at 5 years and 83% +/- 9% at 8 years., Conclusions: A more aggressive approach to resection of diseased valvular tissue with subsequent reconstruction is feasible, with good midterm results, and may extend the scope of valve repair in rheumatic disease patients.

Objective: Valve repair for aortic insufficiency requires a tailored surgical approach determined by the leaflet and aortic disease. Over the past decade, we have developed a functional classification of AI, which guides repair strategy and can predict outcome. In this study, we analyze our experience with a systematic approach to aortic valve repair., Methods: From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age - 54 +/- 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism., Results: In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29-73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 +/- 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 +/- 3% and 92 +/- 4% respectively and patients with type I (82 +/- 9%; 93 +/- 5%) or II (95 +/- 5%; 94 +/- 6%) had better outcomes compared to type III (76 +/- 17%; 84 +/- 13%)., Conclusion: Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair.

Objective: Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficiency (AI). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair., Methods: From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n=72) or more than one leaflet (n=74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n=39), PL (n=25) or GTx+PL (n=23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n=13) or TR or PP+GTx (n=47)., Results: There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent AI and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9-136). Three patients needed late reoperation for recurrent AI. At 4 years, overall survival was 99+/-1% and freedom from reoperation and from recurrent AI (grade >2) was 94+/-5% and 91+/-7% respectively. Freedom from recurrent AI was similar in patients having one versus more than one LP repair (88+/-11% vs 92+/-8%, p=0.2) and among the different techniques used to repair leaflet of good quality (PL: 95+/-8% vs GTx: 83+/-18% vs PL+GTx: 100%; p=0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of AI (TR or PP: 82+/-18% vs TR or PP+GTx: 97+/-4%; p=0.026)., Conclusions: Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet prolapse repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved.

Objective: Despite its theoretic advantage over saphenous vein grafts, the right gastroepiploic artery graft has not been accepted as the ideal conduit to revascularize the right coronary artery. We therefore prospectively randomized these 2 grafts types to compare their clinical, functional, and angiographic evolution at 6 months and 3 years., Methods: From 2003 to 2006, 1397 consecutive patients underwent isolated revascularization at the University of Louvain Medical School. Of this group, 370 patients met the inclusion criteria for randomization and 66% of those were randomized. The right coronary artery was revascularized with saphenous vein grafts in 116 patients and with right gastroepiploic arteries in 122 patients. All patients underwent angiographic control 6 months postoperatively. The end points were major adverse cerebrocardiovascular events and proportion of grafts patent or functional at follow-up angiography., Results: There were no significant differences between the 2 groups in terms of hospital events. At follow-up there was no significant difference in major adverse cerebrocardiovascular events between the 2 groups. At the 6-month angiographic follow-up, 91% of the anastomoses in the right gastroepiploic artery group and 95% of the anastomoses in the saphenous vein graft group were controlled patent (P = .92). In nonoccluded right coronary arteries, the proportion of patent grafts was significantly lower and the proportion of nonfunctioning grafts was significantly higher in the right gastroepiploic artery group than in the saphenous vein graft group., Conclusion: There were no significant patency or major adverse cerebrocardiovascular events rate differences between the 2 groups; however, the number of functional grafts was significantly higher in the saphenous vein graft group. Careful selection of the coronary target is mandatory to obtain good results in gastroepiploic artery grafting.

Objectives: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality., Methods: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality., Results: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p<0.0001)., Conclusions: Deep sternal wound infection (DSWI) remains a dreadful complication in contemporary cardiac surgery while risk factors are currently well defined. Using a simple approach of primary closure together with liberal use of vascularized flaps has allowed us to achieve satisfactory short-term outcome in this subset of patients.

Background: Preoperative intraaortic balloon pump (IABP) counterpulsation has better outcomes compared with perioperative or postoperative insertion in critical patients, and off-pump surgical procedures have been advocated to reduce mortality in high-risk patients. However, some surgeons are reluctant to perform beating heart operations in specific patient subgroups, including those with unstable angina or patients with low ejection fraction, because of their possible perioperative hemodynamic instability., Methods: We evaluated combined beating heart procedures and preoperative IABP in selected high-risk patients and compared our results with the predictive European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. Fifty-five high-risk patients with a mean logistic EuroSCORE of 24 were prospectively enrolled and then divided into emergency (group 1, n = 25) and nonemergency (group 2, n = 30) groups. IABP was inserted immediately before operation in group 1 and the day before the procedure in group 2., Results: Compared with the EuroSCORE predictive model, a dramatic decrease in mortality occurred in both groups. Group I predicted mortality was 36.8%, and observed was 20%; and group 2 predicted mortality was 15.2% and observed was 0%. No specific complications from the use of IABP were encountered. During mid-term (2 years) follow-up, no patient died from a cardiac cause or required percutaneous coronary intervention or subsequent reoperation due to incomplete revascularization., Conclusions: The combined use of preoperative intraaortic counterpulsation and beating heart intervention allows complete revascularization in high-risk patients with a important reduction in operative mortality and excellent mid-term results.

Objective: To evaluate timing for surgery and management of complex valve lesions in patients with active mitral valve (MV) endocarditis. Results are based on 13 years of experience with MV repair in active endocarditis., Method: Between 1993 and 2005, 81 patients were operated for active MV endocarditis, of which 63 (or 78%) had MV repair. For all patients, the median time between diagnosis and surgery was 10 days. Diverse surgical techniques were applied to restore MV competence. In 59% of the patients, pericardial patches, tricuspid autograft or partial MV homografts were used as leaflet substitutes. In addition, prosthetic rings were employed in 44% of the patients., Results: The overall operative mortality was 17.5%. However, considering only patients in preoperative NYHA class I or II, the operative mortality could be reduced to 4.8%. NYHA class > or =3, elevated age (above 70 years) and history of valvular were the three independent risks factors for early mortality in our multivariate analysis. The average follow-up time was 60+/-37 months. During this period, five late deaths occurred, two of which were cardiac-related. The overall 5- and 10-year survival rate was 73+/-12% and 69+/-13%, respectively. In hospital survivors, freedom from cardiac death after 5 and 10 years was 93+/-8%. Three early and five late MV reoperations occurred in seven patients, of them four could have MV re-repair. Only one endocarditis recurrence occurred after 4 months in a chronic haeamodialysed patient. Freedom from MV reoperation was 89+/-10% and 72+/-24% at 5 and 10 years, respectively. Ten-year freedom from MV replacement and from endocarditis recurrence were 95+/-5% and 98+/-1%, respectively. Annular abscesses and calcified or rheumatic MV disease were two independent risk factors associated with reoperation in our multivariate analysis. During the follow-up period, all patients were in NYHA class I or II; 89% of patients had mitral regurgitation grade < or =I, only 11% had grade II on transthoracic echocardiography., Conclusion: Using diverse and advanced techniques of MV repair, a reparability rate of 80% can be reached among patients with active endocarditis. We demonstrate that a high level of safety and excellent durability of MV repair can be obtained even for complex repairs.

Quadricuspid aortic valve in adulthood is a rare pathology which often leads to aortic valve regurgitation that requires surgical treatment. Herein are described two patients with severe regurgitation on a quadricuspid aortic valve and with dilated left ventricle, who where successfully repaired using a technique of tricuspidation of the valve at the level of the abnormal commissure. In each patient, the repair was stabilized and leaflet coaptation increased by subcommissural annuloplasty stitches at the level of the three commissures. After one year and six months' follow up, respectively, both patients presented with trivial aortic regurgitation and good mobility of the three leaflets.

Background: Although the internal thoracic artery was proven superior to saphenous vein graft in long-term patency, it is thought to be a more resistive conduit than the vein graft. Moreover, patency studies comparing both left and right internal thoracic arteries have provided results favoring the former. Fractional flow reserve is an established functional index of coronary blood flow., Methods: To compare the fractional flow reserve between both internal thoracic arteries and saphenous vein grafts, 43 bypass grafts were studied 6 months after revascularization. Intra-graft pressures were measured during cardiac catheterization using a pressure-wire advanced to the first distal anastomosis of 12 left internal thoracic arteries (ITAs), 10 right ITAs and of 21 vein grafts. Pressure gradients between the aorta and the graft were measured at baseline and during a maximal hyperemia., Results: At baseline, pressure gradient was recorded in the left ITA (2.9+/-2.2 mmHg), in the right ITA (1.2+/-1.2 mmHg) and in the vein graft (0.4+/-0.7 mmHg). During maximal hyperemia, pressure gradient increased to 9.6+/-3.2 mmHg in left ITA, to 4.5+/-2.0 mmHg in the right ITA (p<0.001 vs left ITA) and to 3.3+/-2.7 mmHg in vein (p<0.001 vs left ITA; NS vs right ITA). Fractional flow reserve was 0.90+/-0.04 in left ITA, 0.95+/-0.03 in right ITA (p<0.01 vs left ITA) and 0.96+/-0.03 in vein (p<0.001 vs left ITA)., Conclusion: Internal thoracic arteries and saphenous vein grafts allow myocardial revascularization with minimal resistance to maximal blood flow. The resistance appears significantly higher in left ITA compared to both the right ITA and venous grafts.

Background: Combined aortic valve repair and aortic valve-sparing surgery requires an approach determined by the leaflets and aortic root anatomy., Methods: Among patients referred for aortic root aneurysm, 114 patients underwent an aortic valve-sparing procedure in which a reimplantation or remodelling technique was used. The Gelweave Valsalva prosthesis (Sulzer Vascutek, Renfrewshire, UK) was used in 45 patients. Better molding of the prosthesis on the aortic annulus was achieved by a low proximal dissection and incisions on the prosthesis to respect the anatomy of the aortoventricular junction. The reimplantation technique was used in 58%, and 62% of all patients underwent an associated leaflet procedure., Results: The operative mortality rate was 1%, with a 2% immediate reoperation rate. During the mean follow-up 50 +/- 35 months, 3 patients (2.6%) needed reoperation for recurrent aortic regurgitation (n = 2) or aortic stenosis (n = 1). At the end of follow-up, aortic regurgitation grade exceeding 2 had occurred in 2.6% of patients (n = 3), and 98.2% were in New York Heart Association functional class 1 or 2. Neither the early nor mid-term results showed any differences among the different surgical techniques used (reimplantation, remodeling, Valsalva prosthesis, additional leaflet repair)., Conclusions: A complete approach to the different components of the aortic root allows good clinical results at mid-term.

We report the case of aortic valve-papillary fibroelastoma in a 66-year-old Belgian woman with a previous single episode of cerebral transient ischemic attack. Transthoracic two-dimensional echocardiography revealed a small mass adherent to the noncoronary cusp of the valve, which was confirmed by transesophageal echocardiography. Indication for surgery was performed because of a previous cerebral transient ischemic attack and for its potential risk of cerebral and coronary embolization. Surgical excision of the mass was performed with the need for glutaraldehyde-treated autologous pericardial patch repair of the aortic cusp. Intraoperative and postoperative transesophageal echocardiography both showed the valve to be competent. Postoperative recovery was uneventful. After a review of the literature, we conclude that, even if asymptomatic, and independent of their size, aortic valve papillary fibroelastomas justify surgical excision for their potential to systemic embolization. Moreover, we believe that a valve-sparing approach might be feasible with no recurrence after complete excision.

Background: Patients with patent grafted bilateral internal thoracic arteries may require repeat myocardial revascularization because of either progression of disease in a nongrafted native vessel or failure of a saphenous vein graft. In order to avoid extensive dissection and possible damage of the internal thoracic arteries, we elected to proceed with an off-pump minimally invasive direct coronary artery bypass grafting (MIDCABG) approach using the pedicled right gastroepiploic artery. This paper summarizes our midterm angiographic results., Methods: From 1996 to 2003, 15 patients were reoperated on using this approach in our department. Internal thoracic artery grafts always revascularized the anterior and lateral territories and were angiographically patent. Indications for repeated surgery were: (1) coronary disease progression in 8 patients; (2) occlusion of the saphenous vein graft in 6 patients; and (3) anastomotic stenosis of a pedicled right gastroepiploic artery in 1 patient. Off-pump grafting of the pedicled right gastroepiploic artery was targeted at the posterior descending artery in 14 patients, and at the left anterior descending artery in 1 patient., Results: Thirty-day mortality was 6.5% (1 of 15 patients). With a mean follow-up of 56 +/- 20 months, angina-free survival was 79%. At angiographic control (mean, 38 months), the pedicled right gastroepiploic artery was patent in 13 patients. One patient had an occluded right gastroepiploic artery graft at 23 months and another patient showed progression of disease distal to the right gastroepiploic artery anastomosis at 28 months., Conclusions: Off-pump MIDCABG repeat revascularization with a pedicled right gastroepiploic artery is an effective method of revascularization for patients with patent bilateral internal thoracic arteries.

Objective: To assess the feasibility, safety, and outcome of laparoscopic liver resection for malignant liver tumors., Summary Background Data: The precise role of laparoscopy in resection of liver malignancies (hepatocellular carcinoma [HCC] and liver metastases) remains controversial despite an increasing number of publications reporting laparoscopic resection of benign liver tumors., Methods: A retrospective study was performed in 11 surgical centers in Europe regarding their experience with laparoscopic resection of liver malignancies. Detailed questionnaires were sent to each surgeon focusing on patient characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. All patients had radiologic investigations at follow-up to exclude disease recurrence., Results: From February 1994 to December 2000, 37 patients with malignant liver tumors were included in this study. Ten patients had HCC, including 9 with cirrhotic liver, and 27 patients had liver metastases. The mean tumor size was 3.3 cm, and 89% of the tumors were located in the left lobe or in the anterior segments of the right liver. Liver procedures included 12 wedge resections, 9 segmentectomies, 14 bisegmentectomies (including 13 left lateral segmentectomies), and 2 major hepatectomies. The transfusion rate, the use of pedicular clamping, the conversion rate (13.5% in the whole series), and the complication rate were significantly greater in patients with HCC. There were no deaths. Postoperative complications occurred in eight patients (22%). The surgical margin was less than 1 cm in 30% of the patients. During a mean follow-up of 14 months, the 2-year disease-free survival was 44% for patients with HCC and 53% for patients having hepatic metastases from colorectal cancer. No port-site metastases were observed during follow-up., Conclusions: In patients with small malignant tumors, located in the left lateral segments or in the anterior segments of the right liver, laparoscopic resection is feasible and safe. The complication rate is low, except in patients with HCC on cirrhotic liver. By using laparoscopic ultrasound, a 1-cm free surgical margin should be routinely obtained. The late outcome needs to be evaluated in expert centers.

Hypothesis: Resection of intraductal papillary mucinous tumors of the pancreas (IPMTP) should be tailored to longitudinal spreading into the pancreatic ductal system and the presence of malignant transformation., Objective: To review a single institutional experience with IPMTP, focusing on the operative strategy of tailoring resection to the extent of disease., Design: Retrospective study., Setting: Academic tertiary referral center., Patients: Thirteen patients with IPMTP were referred for resection during the past 10 years. Malignant growth was present in 7 patients (54%). According to the determination of tumor extent, distal pancreatic resection was performed in 3 patients, pancreatoduodenectomy was done in 9 patients, and total pancreatectomy was performed in 1 patient. The median follow-up time in this series was 46 months (range, 3-104 months)., Main Outcome Measures: Preoperative and perioperative diagnosis, final pathologic results, and long-term outcome., Results: A correct preoperative or perioperative diagnosis of IPMTP was achieved in 9 patients (69%). Routine frozen section of the surgical margin was used in all patients, changing the operative strategy in 3 (23%) of 13 patients by extending resection or leading to total pancreatectomy in 2 patients and 1 patient, respectively. A perioperative endoscopic examination of the Wirsung duct was performed in 3 patients with a correct preoperative or perioperative diagnosis of IPMTP and a dilated pancreatic duct. This allowed the examination of the entire pancreatic ductal system and staged intraductal biopsies, changing the operative strategy in 1 of these patients. Finally, after pancreatoduodenectomy, pancreaticogastric anastomosis was constructed in 5 patients, allowing endoscopic assessment of the pancreatic stump during long-term follow-up. The 5-year actuarial survival rate was 56.8% in the whole series. All patients with benign or microinvasive malignant disease remained disease-free, whereas all patients with invasive malignant disease died of tumor recurrence., Conclusions: Accurate determination of the extent of ductal disease and residual malignant growth, when present, is critical during surgical exploration to achieve radical resection and cure. Operative strategy should be based on routine frozen section of the surgical margin and perioperative endoscopic examination of the Wirsung duct with staged intraductal biopsies when technically feasible. The routine use of pancreaticogastric anastomosis after pancreatoduodenectomy allows easy, safe, and efficient long-term endoscopic assessment of the pancreatic stump.

Objective: Recently we reviewed the 10-year clinical and angiographic outcomes of sequential internal thoracic artery grafting. Most of the patients also received complementary saphenous grafts, and their overall long-term patency rates were surprisingly high. Therefore, we decided to analyze these results in more detail., Methods: The first consecutive 500 patients having received at least one sequential internal thoracic artery graft between October 1985 and August 1991 were restudied retrospectively. The saphenous grafts were only used to achieve complete revascularization in addition to complex arterial grafting on less significant or remote coronary vessels. A total of 161 patients consented to a late angiographic restudy at a mean postoperative interval of 7.5 years (1-12.2 years)., Results: At 5 and 10 years postoperatively, freedom from angina was 96% and 82%, and freedom from any cardiac event was 92.8% and 69%, respectively. Only 15 (3.1%) patients needed additional revascularization (0.3% per patient-year): 4 coronary artery bypass grafting (0.8%) and 11 percutaneous transluminal coronary angioplasty (2.3%). The overall patency and intactness rates of saphenous anastomoses were 72.5% and 60.2%, respectively. There was a significant difference between the patency and intactness of sequential versus single anastomoses: 76% versus 60% and 64.5% versus 44.4%, respectively. There was no significant difference in either patency or intactness between right internal thoracic and sequential saphenous grafts anastomosed to the right coronary artery: 83.4% versus 75.2% and 77.8% versus 62.4%, respectively. The same was true for the anastomoses to the "remote area" (distal circumflex, distal right coronary artery)., Conclusions: Complementary sequential saphenous grafting still deserves consideration in some patients below 70 years of age, particularly for those with disease in the "remote area": the distal circumflex and right coronary branches.

Objective: To evaluate the long-term outcome of patients with esophageal cancer after resection of the extraesophageal component of the neoplastic process en bloc with the esophageal tube., Summary Background Data: Opinions are conflicting about the addition of extended resection of locoregional lymph nodes and soft tissue to removal of the esophageal tube., Methods: Esophagectomy performed en bloc with locoregional lymph nodes and resulting in a real skeletonization of the nonresectable anatomical structures adjacent to the esophagus was attempted in 324 patients. The esophagus was removed using a right thoracic (n = 208), transdiaphragmatic (n = 39), or left thoracic (n = 77) approach. Lymphadenectomy was performed in the upper abdomen and lower mediastinum in all patients. It was extended over the upper mediastinum when a right thoracic approach was used and up to the neck in 17 patients. Esophagectomy was carried out flush with the esophageal wall as soon as it became obvious that a macroscopically complete resection was not feasible. Neoplastic processes were classified according to completeness of the resection, depth of wall penetration, and lymph node involvement., Results: Skeletonizing en bloc esophagectomy was feasible in 235 of the 324 patients (73%). The 5-year survival rate, including in-hospital deaths (5%), was 35% (324 patients); it was 64% in the 117 patients with an intramural neoplastic process versus 19% in the 207 patients having neoplastic tissue outside the esophageal wall or surgical margins (P <.0001). The latter 19% represented 12% of the whole series. The 5-year survival rate after skeletonizing en bloc esophagectomy was 49% (235 patients), 49% for squamous cell versus 47% for glandular carcinomas (P =.4599), 64% for patients with an intramural tumor versus 34% for those with extraesophageal neoplastic tissue (P <.0001), and 43% for patients with fewer than five metastatic nodes versus 11% for those with involvement of five or more lymph nodes (P =.0001)., Conclusions: The strategy of attempting skeletonizing en bloc esophagectomy in all patients offers long-term survival to one third of the patients with resectable extraesophageal neoplastic tissues. These patients represent 12% of the patients with esophageal cancer suitable for esophagectomy and 19% of those having neoplastic tissue outside the esophageal wall or surgical margins.

Background: Patients with aneurysms of the ascending aorta or aortic root may have associated aortic insufficiency (AI). We reviewed our experience with aortic root remodeling and reconstruction of the sino-tubular junction., Methods: Forty-five patients were operated on between July 1995 and September 1998. Transesophageal echocardiography showed AI grade III or IV in 15 patients. Twenty-seven patients had replacement of all three sinuses, 10 of one or two sinuses. Reconstruction of the sino-tubular junction alone was performed in 8 patients., Results: There was one death at 28 days. Perioperative transesophageal echocardiography showed no or discrete AI in all patients. There has been one aortic valve replacement at day 4 postoperatively for cusp repair failure. Transesophageal echocardiography in 40 patients at a mean time of 12.5 months showed no progression of AI in 38 patients, and a grade II in 2. Clinical follow-up averaged 14.5 months. There have been three late, not procedure-related deaths. Thirty-six patients are in New York Heart Association functional class I. There have been no cases of endocarditis., Conclusions: Aortic remodeling is successful in eliminating AI in patients with aortic root disease with minimal mortality and morbidity. Early echocardiography (1 year) has shown no progression of AI in 95% of cases.

Background: To overcome problems of lack of conduit and to maximize the number of arterial anastomoses in coronary reoperations we reused previously placed arterial grafts., Methods: Sixteen patients were identified from February 1994 to July 1997. Mean age was 62.8 years (range, 44 to 75 years). Fifteen (94%) were in Canadian Cardiovascular Society angina class III or IV. The mean interval from primary to secondary operation was 8.5 years (range, 3 to 12 years). Eleven patients had a patent internal mammary artery graft used as the recipient for a proximal Y anastomosis. In 3 cases an arterial graft was reimplanted distally on the same coronary vessel and in 2 onto different coronary vessels. One patient had a combination of these techniques. Five patients required venous conduit., Results: There were no deaths. Mean length of intensive care stay was 69 hours (range, 24 to 144) and mean hospital stay was 14 days (range, 10 to 28 days). All patients were discharged home. Follow-up averages 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society angina class I and 3 (19%) in class II., Conclusions: Reusing arterial conduits during coronary reoperations is possible with minimal in-hospital morbidity and satisfactory results in terms of freedom from angina. Using these techniques can help overcome the problems of inadequate conduit and maximize the number of arterial anastomoses that can be made per patient.