Stress testing-guided assessment of coronary artery bypass grafts patency, at 6 months of follow up. A prospective study

Purpose: To assess the coronary bypass grafts patency and the repeat revascularization rate, six months after coronary artery bypass grafting (CABG). Methods: We prospectively enrolled 145 consecutive patients undergoing isolated CABG between June 2014 and June 2016. We performed at 6 months of follow up a coronary computed tomography angiography (CTA) in patients whose stress tests were negative and an invasive coronary angiography (ICA) in the opposite case. Results: A total of 134 CTA and 11 ICA were performed, allowing the analysis of 321 grafts, including 143 left internal thoracic arteries (LITA), 89 right internal thoracic arteries (RITA) and 89 saphenous veins grafts (SVG). The average graft patency was 95.1% for LITA, 84.3% for RITA and 64% for SVG. The best patencies were obtained when these grafts were anastomosed to the left anterior descending artery (LAD): 96.3% for LITA, and 87.5% for RITA. SVG patency was homogeneous whether between the main right coronary artery and its branches (63.4% versus 65% respectively. p = 1), or between circumflex and RCA (72.7% versus. 63.9% respectively. p=0.6). On the right and circumflex coronary arteries, the patency of the SVG was significantly lower than that of RITA (66.26% versus 83.95% respectively, p = 0.011). At 6 months of follow up, the repeat revascularization rate was 2.07% (n=3/145). Conclusions: 6 months after CABG, RITA and LITA had good patencies especially on LAD, while SVG was occluded in almost a third of cases. On the circumflex and right coronary arteries, SVG patency was significantly lower than that of RITA. Keywords: Coronary Artery Bypass; Exercise Testing; Coronary Angiography; Computed Tomography Angiograph

Transit time flow measurement of coronary bypass grafts before and after protamine administration

Background Intraoperative graft assessment with tools like Transit Time Flow Measurement (TTFM) is imperative for quality control in coronary surgery. We investigated the variation of TTFM parameters before and after protamine administration to identify new benchmark parameters for graft quality assessment. Methods The database of the REQUEST (“REgistry for QUality AssESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery”) study was retrospectively reviewed. A per graft analysis was performed. Only single grafts (i.e., no sequential nor composite grafts) where both pre- and post-protamine TTFM values were recorded with an acoustical coupling index > 30% were included. Grafts with incomplete data and mixed grafts (arterio-venous) were excluded. A second analysis was performed including single grafts only in the same MAP range pre- and post- protamine administration. Results After adjusting for MAP, we found a small increase in MGF (29 mL/min to 30 mL/min, p = 0.009) and decrease in PI (2.3 to 2.2, p < 0.001) were observed after the administration of protamine. These changes were especially notable for venous conduits and for CABG procedures performed on-pump. Conclusion The small changes in TTFM parameters observed before and after protamine administration seem to be clinically irrelevant, despite being statistically significant in aggregate. Our data do not support a need to perform TTFM measurements both before and after protamine administration. A single TTFM measurement taken either before or after protamine may suffice to achieve reliable data on each graft’s performance. Depending on the specific clinical situation and intraoperative changes, more measurements may be informative. Trial registration Clinical Trials Number: NCT02385344, registered February 17th, 2015.

An original method of pericardium closure after coronary artery bypass grafting

<p>Different cardiac surgery centres have different views regarding pericardial suturing. However, there is limited scientific evidence confirming the advantage of one method over another, which disallows us from forming a general opinion regarding specialists. Here, we describe several well-known methods of suturing the pericardium and preventing traumatisation of coronary bypass grafts and analyse their weaknesses. An original technique of opening and suturing the pericardium is proposed to restore the physiological distinction between the pericardial cavity and the anterior mediastinum during coronary artery bypass grafting without the risk of compromising the functioning coronary bypass grafts and narrow mediastinal syndrome.<br />The proposed method of suturing the pericardium received a patent for invention, No. 2733505, dated 2 October, 2020. In the A.N. Bakulev National Medical Research Center for Cardiovascular Surgery (Moscow, Russian Federation), this technique of suturing the pericardium has been routinely used since 2006. More than 2,000 intraoperative shunt scans have been performed in our department since 2009; all these scans were performed after the pericardium was closed, proving that the fear of compromising the shunts during pericardial suturing is unsupported.</p><p>Received 17 December 2020. Revised 13 January 2021. Accepted 18 January 2021.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p><strong>Author contributions</strong><br />Conception and study design: G.G. Kvaratskheliya, E.P. Golubev<br />Data collection and analysis: U.S. Avkhadov, R.M. Ibragimov<br />Drafting the article: G.G. Kvaratskheliya, E.P. Golubev<br />Critical revision of the article: E.U. Asymbekova, B.E. Rustamov, L.S. Shakhnazaryan, Yu.I. Buziashvili<br />Final approval of the version to be published: G.G. Kvaratskheliya, E.P. Golubev, U.S. Avkhadov, R.M. Ibragimov, B.E. Rustamov, E.U. Asymbekova, L.S. Shakhnazaryan, Yu.I. Buziashvili</p><p> </p>

Personal experience in 207 Bentall procedures

This work is based on the greatest experience in Venezuela in the surgical treatment of the aortic root in pathologies that require a Bentall procedure. It represents the experience in the 207 cases carried out with this procedure; types of prosthetics and grafts, techniques used, observed care, results, complications, and mortality. Of Bentall’s interventions, 59 cases (27.4 %) were done with total circulatory arrest in deep hypothermia at 18 oC. As associated procedures, 21 patients received aorto-coronary bypass grafts and 10 patients also had mitral valve replacement. The overall operative mortality of the sample was 12.5 %. The success rate of this experience was 87.5 %, fully justifying the completion of the procedure in the pathology of very high mortality, especially when referring to dissections.

Risk factors for fatal drowning in a Greek region: a retrospective case–control study

BackgroundFatal drowning is one of the leading causes of unintentional injury mortality worldwide and a persistent public health concern in Greece. While several pathologic and sociodemographic contributing factors have been previously identified, these have not been extensively investigated in conjunction with the effects of psychoactive substances.MethodsA retrospective case–control study of drowning deaths was conducted in the Greek regions of Northern Greece and Thessaly during a 10-year period. A regression model was constructed examining differences in detected substances, autopsy findings and sociodemographic characteristics between 240 victims of unintentional fatal submersion and 480 victims of other causes of sudden or violent death.ResultsThe majority of victims were males (69.4%) and foreign nationality was associated with increased odds of drowning. Cardiomegaly and coronary bypass grafts were significantly more likely to have been recorded among drowning victims, while the frequency of other circulatory system disorders was also elevated. Several of these findings were potential arrhythmogenic substrates which could adversely interact with the diving reflex. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly detected pharmacological group (9.0%), and along with tramadol, there was an increased likelihood of exposure to them. These drugs have been previously associated with QT prolongation and other adverse effects which may contribute to fatal outcomes in a seawater environment. In contrast, there was a decreased risk of exposure to dependence-inducing drugs and paracetamol.ConclusionsMale sex, older age, foreign nationality and cardiovascular disease predisposed individuals to an elevated risk of fatal submersion. SSRI antidepressants and tramadol may contribute to this outcome.

Coronary-coronary bypass grafting: artery or vein?

Background The method of coronary-coronary bypass grafting was described in 1987 but has not been widely used, and there are only a few studies that report good short-term and mid-term results as well as some individual cases of long-term follow-up. In our medical institution, we carried out an analysis of the long-term results of coronary-coronary bypass grafting, which are presented in this study. Methods This was a retrospective single-center study on 95 patients who underwent coronary-coronary bypass grafting as a supplement to the standard coronary bypass grafting procedure. All patients underwent angiographic assessment of the coronary bypass grafts during the long-term follow-up period. The observation period was up to 123 months. Angiographic assessment of 109 coronary-coronary grafts was carried out. Results Twelve (7.6%) arterial and 11 (19.3%) venous conduits were found to be occluded, and 8 (10.3%) arterial and 10 (31.3%) venous coronary-coronary grafts were occluded during the observation period. Conclusion Arterial coronary-coronary artery bypass grafting represents an alternative technique that allows complete myocardial revascularization.

Predictive value of great saphenous vein mapping prior to endoscopic harvesting in coronary artery bypass surgery

OBJECTIVES The use of endoscopic vein harvesting in patients undergoing coronary artery bypass grafting is increasing, often using bedside mapping. However, data on the predictive value of great saphenous vein (GSV) mapping are scarce. This study assessed whether preoperative mapping could predict final conduit diameter. METHODS A prospective registry was created that included 251 patients. Saphenous vein mapping was performed prior to endoscopic vein harvesting at 3 predetermined sites. After harvesting and preparing the GSV, the outer diameters were measured. Appropriate graft size was defined as an outer diameter between 3 and 6 mm. RESULTS A total of 753 GSV segments were analysed. The average mapping diameter was 3.2 ± 0.7 mm. The harvested GSV had a mean diameter of 4.7 ± 0.8 mm. Mapping diameters were significantly positively correlated with actual GSV diameters (correlation coefficient, 0.47; P &lt; 0.001). If the preoperative mapping diameters were between 1.5 and 5 mm, 96.6% of the GSVs had suitable dimensions after endoscopic vein harvesting. CONCLUSIONS Preoperative bedside mapping moderately predicts final GSV size after endoscopic harvesting but could not detect unsuitable vein segments. However, the majority of endoscopically harvested GSVs had diameters suitable to be used as coronary bypass grafts.

Role of Computerized Tomography in Evaluation of Coronary Bypass Grafts—Special Reference to Women

Computerized tomography-coronary angiography (CT-CAG) is gaining popularity as an alternative to conventional CAG to evaluate grafts in a post-coronary artery bypass graft (post-CABG) patient, since it is a noninvasive procedure and is less influenced by cardiac motion. The primary challenge is to image a rapidly beating heart. With introduction of 64-slice scanner, the coronary imaging became a possibility with acceptable accuracy. In recent years, with the development of 128,256 and 320 multislice CT scanners, further enhancement in the temporal and spatial resolution is achieved due to lesser influence of the respiratory and cardiac motion, enhancing the accuracy of the lesion assessment in the grafts and the native vessels. Achieving low heart rate and artifact-free image acquisition, proper reconstruction, and image interpretation are challenges to the radiologists and the technicians involved in coronary imaging. Women pose special subset because of smaller sized coronary vessels, interference due to breast shadows, low-referrals, and gender-specific reluctance to accept the procedure itself. Cardiologists and radiologists caring for these patients must be familiar with the pros and cons of CT-CAG and gender-specific challenges.