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Darryl M Hoffman, Robert F Tranbaugh Division of Cardiothoracic Surgery, Beth Israel Medical Center, New York, NY, USA Abstract: Diabetes increases both the severity and the risks of coronary artery disease. For such patients, revascularization by coronary artery bypass grafting (CABG) has consistently improved survival and event free survival in multiple studies compared to percutaneous revascularization (PCI). Evolving treatments, the growing volume of patients with diabetes who have coronary disease, and the cost of their care mandates regular reevaluation of the evidence on which treatment by CABG or PCI is based. This review provides current perspectives on the role of CABG based on analysis of information from newly reported major trials such as Taxus drug eluting stent versus coronary artery bypass surgery (SYNTAX) and Future revascularization evaluation in patients with diabetes mellitus:optimal management of multiple vessel disease (FREEDOM). Also evaluated are technical advances in CABG and improvements in the care of CABG patients with diabetes which should be incorporated in "best practice" surgical revascularization. The accumulated evidence shows clear superiority of CABG for patients with diabetes and multivessel disease, and in particular the benefits of CABG employing multiple arterial conduits. Keywords: Diabetes mellitus, coronary atherosclerosis, revascularization, coronary stent

BACKGROUND: Radial artery (RA) grafts are an attractive second arterial conduit after the left internal thoracic artery (LITA) for coronary artery bypass graft (CABG) surgery. However, long-term outcomes and the need for subsequent reintervention have not been defined. METHODS AND RESULTS: We performed a retrospective cohort study of our single institution's 16-year experience with 1851 consecutive patients (average age, 58 years; 82% men, 36% diabetic) undergoing primary, isolated CABG with the LITA, RA, and saphenous vein as needed. Average grafts per patient were 3.8, with 2.4 arterial grafts per patient. Survival was determined using the Social Security Death Index. Grafts were nonpatent if they had a >50% stenosis, a string sign, or were occluded. Five patients (0.3%) died in hospital and 0.8% had a myocardial infarction, 1.1% a stroke, and 0.6% renal failure. Kaplan-Meier-estimated 1-, 5-, 10-, and 15-year survival was 99%, 96%, 89%, and 75%, respectively. Of the cohort, 278 symptomatic patients underwent cardiac catheterization at our institution an average of 5.0±3.8 years (range, 0.1-12 years) after CABG. Overall RA (n=420 grafts) patency was 82% and SV (n=364 grafts) patency, 47% (P<0.0001). LITA (n=287 grafts including 9 sequential grafts) patency was 85% and right internal thoracic artery (n=15 grafts) patency was 80% (P=0.6). RA patency was not different from LITA patency (P=0.3). Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively. CONCLUSIONS: RA grafting is a highly effective revascularization strategy providing excellent short and long-term outcomes with very low rates of reintervention. RA patency is similar to LITA patency and is much better than SV patency. RA grafting should be more widely utilized in patients undergoing CABG. [ABSTRACT FROM AUTHOR]

Background and Purpose: The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self-fulfilling prophecy (by treatment withdrawal or organ donation). We meta-analyzed the natural history of BD when somatic support (SS) is maintained., Methods: Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient-level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including "functionally brain-dead" patients (FBD; i.e. after the pronouncement of brain-death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival., Results: Forty-seven articles were selected (1610 patients, years: 1969-2021). In BD patients with SS, median age was 32.9 years (range = newborn-85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8-100). Mean somatic survival was 8.0 days (range = 1.6 h-19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = -11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival)., Conclusions: BD diagnosis is reliable. Diagnostic criteria should be fine-tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival., (© 2024 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Objective: In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair., Methods: Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression., Results: From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02)., Conclusions: Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aimed to characterize the natural progression and recurrence of new-onset postoperative atrial fibrillation (POAF) during an intermediate-term follow-up post cardiac surgery by using continuous event monitoring., Background: New-onset POAF is a common complication after cardiac surgery and is associated with an increased risk for stroke and all-cause mortality. Long-term data on new POAF recurrence and anticoagulation remain sparse., Methods: This is a single-center, prospective observational study evaluating 42 patients undergoing cardiac surgery and diagnosed during indexed admission with new-onset, transient, POAF between May 2015 and December 2019. Before discharge, all patients received implantable loop recorders for continuous monitoring. Study outcomes were the presence and timing of atrial fibrillation (AF) recurrence (first, second, and more than 2 AF recurrences), all-cause mortality, and cerebrovascular accidents. A "per-month interval" analysis of proportion of patients with any AF recurrence was assessed and reported per period of follow-up time. Kaplan-Meier analysis was used to calculate the time to first AF recurrence and report the first AF recurrence rates., Results: Forty-two patients (mean age 67.6 ± 9.6 years, 74% male, mean CHADS 2- VASc 3.5 ± 1.5) were evaluated during a mean follow-up of 1.7 ± 1.2 years. AF recurrence after discharge occurred in 30 patients (71%) and of those, 59% had AF episodes equal to or longer than 5 minutes (median AF duration at 1 month was 32 minutes [interquartile range 5.5-106], whereas median AF duration beyond 1 month was 15 minutes [interquartile range 6.3-49]). Twenty-four (80%) of the 30 patients had their first AF recurrence within the first month. During months 1 to 12 follow-up, 76% of patients had any AF recurrences (10% had their first AF recurrence, 43% had their second AF recurrence, and 23% had more than 2 AF recurrences). Beyond 1 year of follow-up, 30% of patients had any AF recurrences (10% had their first AF recurrence, 7% had their second AF recurrence, and 13% had more than 2 AF recurrences). Using Kaplan-Meier analysis, the median time to first AF recurrence was 0.83 months (95% CI: 0.37 to 6) and the detection of first AF recurrence rate at 1, 3, 6, 12, 18, and 24 months was 57.1%, 59.5%, 64.3%, 64.3%, 67.3%, and 73.2%, respectively. During follow-up, there was 1 death ([-] AF recurrence) and 2 cerebrovascular accidents ([+] AF recurrence)., Conclusions: In this study of continuous monitoring with implantable loop recorders, the recurrence of AF in patients who develop transient POAF is common in the first month postoperatively. Of the patients who developed postoperative AF, 76% had any recurrence in months 1 to 12, and 30% had any recurrence beyond 1-year follow-up. Current guidelines recommend anticoagulation for POAF for 30 days. The results of this study warrant further investigation into continued monitoring and longer-term anticoagulation in this population within the context of our findings that AF duration was <30 minutes beyond 1 month., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database., Methods: Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching., Results: We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories., Conclusions: The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients., Methods: Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators., Results: Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P < .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P < .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P < .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P < .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P < .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction., Conclusions: DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Multi-arterial bypass grafting with bilateral internal thoracic (BITA-MABG) or radial (RA-MABG) arteries improves long-term survival, but its increased complexity raises perioperative safety concerns. We compared perioperative outcomes of RA-MABG and BITA-MABG using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD)., Methods: We analysed the 2004-2015 BITA-MABG and RA-MABG experience in STS-ACSD. Primary end points were operative mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios [AOR (95% confidence interval)] were derived via multivariable logistic regression. Sensitivity analyses were done in patient sub-cohorts and based on institutional BITA-utilization rates (<5%, 5-10%, 10-20%, 20-40% and >40%)., Results: Eighty-five thousand nine hundred five RA-MABG (82.5% men; 61 years) and 61 336 BITA-MABG (85.1% men; 59 years) patients were analysed; 41.6% of BITA-MABG and 27.3% of RA-MABG cases came from institutions with low MABG utilization rates (<10%). Unadjusted OM was equivalent for both techniques (BITA-MABG versus RA-MABG: 1.3% vs 1.2%, P = 0.79), while DSWI was lower for RA-MABG (1.0% vs 0.6%, P < 0.001). RA-MABG was associated with lower adjusted OM [AOR = 0.80 (0.69-0.96)] and DSWI [AOR = 0.39 (0.32-0.46)]. Sensitivity analyses confirmed robustness of these findings. Equivalent outcomes were observed at high BITA-use institutions where BITA cases comprised >20% of all cases for OM and ≥40% for DSWI., Conclusions: This analysis of the STS-ACSD showed that RA-MABG is a generally safer form of multi-arterial coronary artery bypass grafting surgery. However, this advantage is mitigated at institutions with substantial BITA experience., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Both the open and endovascular techniques are commonly used for harvesting the radial artery (ORAH and ERAH, respectively), and yet, very little is known about the effects of these 2 techniques on endothelial integrity and function of the radial artery (RA). The aim of this study was to assess the endothelial integrity and function of RA harvested using the 2 approaches., Methods: Two independent surgical teams working in the same institution routinely use the RA for coronary artery bypass grafting exclusively employing either ORAH or ERAH. Thirty-nine consecutive patients were enrolled in this comparative study. Endothelial function after ORAH or ERAH was assessed by using the wire myograph system. The integrity of the RA endothelium was evaluated by immunohistochemical staining for erythroblast transformation specific-related gene., Results: The vasodilation in response to acetylcholine was significantly higher in RA harvested with ORAH (P ≤ 0.001 versus ERAH). Endothelial integrity was not different between the 2 groups., Conclusions: ORAH is associated with a significantly higher endothelium-dependent vasodilation. Further investigation on the potential implications of these findings in terms of graft spasm and patency as well as clinical outcomes are needed., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The radial artery has been used for coronary artery bypass surgery for more than 25 years. The recent confirmation of the clinical benefits associated with the use of the artery is likely to drive a new interest toward this conduit in the next few years., Methods: A group of surgeons with extensive experience in the systematic use of the radial artery summarize here the key technical aspects of the use of the conduit for coronary bypass operations., Results: Preoperative evaluation of the ulnar collateral circulation and attention to the characteristics of the target vessel are keys for the successful use of the radial artery. Open or endoscopic harvesting can be used, preferentially with the aid of the harmonic scalpel. The use of vasodilatory and antispastic protocols is probably important but poorly supported by the current evidence. The radial artery can be used for multiple grafting strategies with a variable degree of technical complexity., Conclusions: With attention to few technical key points, the radial artery is a versatile conduit that can be easily introduced in the everyday practice of coronary artery bypass surgery., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD)., Methods: Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n = 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n = 3,678, 30.8%) and three arteries (n = 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD., Results: Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD., Conclusions: Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Multiarterial coronary grafting with two arterial grafts leads to improved survival compared with conventional single artery based on left internal thoracic artery to left anterior descending artery and saphenous vein grafts. We investigated whether extending arterial grafting to three or more arterial grafts further improves survival, and whether such a benefit is modified by diabetes mellitus., Methods: We analyzed 15-year coronary artery bypass graft surgery mortality data in 11,931 patients (age 64.3 ± 10.5 years; 3,484 women [29.2%]; 4,377 [36.7%] with diabetes mellitus) derived from three US institutions (1994 to 2011). All underwent primary isolated left internal thoracic artery to left anterior descending artery grafting with at least two grafts: one artery (n = 6,782; 56.9%); two arteries (n = 3,678; 30.8%); or three or more arteries (n = 1,471; 12.3%). Long-term survival was estimated by Kaplan-Meier methods. Propensity score matching and comprehensive covariate adjustment (Cox regression) were used to derive long-term risk-adjusted hazard ratio (HR) with 95% confidence interval (CI) for increasing number of arterial grafts in the overall cohort and for diabetes and no-diabetes cohorts., Results: Radial artery (94%) and right internal thoracic artery (6%) were used as additional arterial grafts. Multivariate analysis in all patients showed that diabetes was associated with decreased survival (HR 1.43, 95% CI: 1.34 to 53), whereas increasing number of arterial grafts was associated with decreased mortality (one artery HR 1.0 [reference]; two arteries HR 0.87, 95% CI: 0.80 to 0.95; and three arteries HR 0.83, 95% CI: 0.72 to 0.95). Pairwise comparisons also showed an incremental benefit of additional arterial grafts: two arteries versus one artery, HR 0.89 (95% CI: 0.80 to 0.98); and three arteries versus one artery, HR 0.80 (95% CI: 0.68 to 0.94). A three-artery versus two-artery survival advantage trend was also noted, but was not significant in either the overall study cohort (HR 0.90, 95% CI: 0.75 to 1.07), the diabetes cohort (HR 0.79, 95% CI: 0.60 to 1.03), or the no-diabetes cohort (HR 01.00, 95% CI: 0.79 to 1.26). Among diabetes patients, the survival advantage of two arteries versus one artery was modest (HR 0.96, 95% CI: 0.72 to 1.11), whereas it was significant for three arteries versus one artery (HR 0.74, 95% CI: 0.58 to 0.96). Analyses of propensity matched subcohorts were also consistent., Conclusions: Increasing number of arterial grafts improves long-term survival and supports extended use of arterial grafts in coronary artery bypass graft surgery, irrespective of diabetes status., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe., Methods: We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate., Results: SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p < 0.001) and RA-MABG (1.19%, p < 0.001). DSWI was higher among BITA-MABG (1.08%, p < 0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p < 0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (<5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p < 0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use., Conclusions: MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This article summarizes the current research on the benefits of using the transradial approach for percutaneous procedures and the radial artery as a conduit for coronary artery bypass surgery. Based on the available evidence, the authors provide recommendations for the use of the radial artery in patients undergoing percutaneous or surgical coronary procedures., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Summary: The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization., The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Failure of mechanical conventional ventilation (MCV) after cardiac surgery portends a dismal prognosis, with extracorporeal membrane oxygenation frequently utilized as a salvage therapy. We describe our experience with high-frequency percussive ventilation (HFPV) as a rescue therapy for hypoxaemia refractory to MCV after cardiac surgery., Methods: In a 6-year retrospective analysis from 2009 to 2015, we identified 16 subjects who required HFPV after cardiac surgery. Data regarding demographics, intraoperative details, postoperative ventilatory settings including length of time on HFPV and postoperative outcomes were collected. The primary outcome was improvement in oxygenation as measured by pre- and post-HFPV partial pressures of oxygen (pO2) and ratio of pO2 to fraction of inspired oxygen (P/F ratio)., Results: Sixteen patients required HFPV after cardiac surgery. Operative procedures included coronary artery bypass surgery (n = 6), aortic aneurysm or dissection repair (n = 5), valve with bypass surgery (n = 2), aortic valve replacement (n = 2) and extracorporeal membrane oxygenation (n = 1). Median pO2 increased from 61 to 149.5 mmHg (P < 0.001) and the median P/F ratio improved from 62 to 169 (P < 0.001). The improvement in pO2 and P/F ratio was durable at 24 h whether the patient was returned to MCV (n = 4) or remained on HFPV (n = 12) with pO2 and P/F ratio increasing from 61 to 104 mmHg (P < 0.001) and from 62 to 193.5 (P < 0.001), respectively. Survival to discharge was 81%., Conclusions: In our cohort of cardiac surgical patients, HFPV was successfully utilized as a rescue therapy, obviating the need for extracorporeal membrane oxygenation. Although further studies are warranted, HFPV should be considered in cardiac surgical patients failing MCV., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: It is not clear whether radial artery (RA), right internal thoracic artery (RITA), or saphenous vein (SV) is the preferred second bypass graft during coronary artery bypass graft surgery using the left internal thoracic artery (LITA) in patients aged less or greater than 70 years., Methods: Late survival data were collected for 13,324 consecutive, isolated, primary coronary artery bypass graft surgery patients from three hospitals. Cox regression analysis was performed on all patients grouped by age., Results: Adjusted Cox regression showed overall better RA versus SV survival (hazard ratio [HR] 0.82, p < 0.001) and no difference in RITA versus SV survival (HR 0.95, p = 0.35). However, the survival benefit of RA versus SV was seen only in patients aged less than 70 years (HR 0.77, p < 0.001); and RITA patients aged less than 70 years also had a survival benefit compared with SV (HR 0.86, p = 0.03). There was no difference in survival for RA versus RITA across all ages., Conclusions: For patients aged less than 70 years, the optimal grafting strategy is using either RA or RITA as the second preferred graft. In patients aged 70 years or more, RA and RITA grafting should be used selectively. Multiple arterial grafting using either RA or RITA should be more widely utilized during coronary artery bypass graft surgery for patients less than 70 years of age., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective(s): We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second arterial conduit for coronary artery bypass grafting., Methods: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method., Results: A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71)., Conclusions: The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG., Methods: Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts., Results: Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively., Conclusions: RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: We sought to estimate the reduction in deaths and the number of additional person-years of life that could potentially be gained by nationwide adoption of routine multiple arterial bypass grafting (MABG)., Methods: Propensity matching on 4883 patients undergoing primary, isolated coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA) from January 1995 to June 2011, resulted in 1023 matched pairs of LITA-radial artery and LITA-saphenous vein patients. Kaplan-Meier estimated survivals were used to calculate the potential number of lives that could be saved based on a 20% and an 80% rate of MABG, compared with the national 10% rate, when applied to a hypothetical national sample of 200,000 similar patients., Results: Our overall MABG rate was 40% with >80% rate for the past 3 years. Kaplan-Meier estimated 10-year survival was better for LITA-radial artery patients (83.1%) compared with LITA-saphenous vein patients (75.7%) (log rank test, P < .001). When compared with the current national 10% MABG rate, a 20% and an 80% MABG rate could potentially result in 1400 and 10,000 fewer annual deaths, respectively, among a hypothetical national cohort, yielding >9000 and >64,000 person-years of life over a 10-year period., Conclusions: An 80% rate of MABG has the potential to prevent more than 10,000 deaths annually and add >64,000 person-years of life over the course of 10 years. The use of a second arterial graft during CABG should be routine in the majority of patients undergoing CABG., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES)., Objectives: This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG)., Methods: We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts., Results: BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001)., Conclusions: Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF)., Methods: We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons., Results: Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results., Conclusions: MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Left atrial dissection is an exceedingly rare but potentially fatal complication of cardiac surgery. It is most commonly associated with mitral valve surgery, including both replacement and repair, with a reported incidence rate of 0.16%. However, other cardiac surgical or catheter-based interventional procedures are also known as potential predisposing factors. The time of presentation from the cause of dissection varies extremely, ranging from immediate occurrence up to 20 years later. The dissection forms a large cavity between the endocardium and epicardium of the left atrium, causing obliteration of the left atrial cavity and resultant haemodynamic compromise, which almost always requires immediate surgical intervention. In contrast, left atrial dissection without haemodynamic instability can often be managed non-operatively with satisfactory outcomes. This article reviews this rare but relevant clinical entity to further elucidate the incidence, pathogenesis, clinical course, management and outcome of left atrial dissection., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revascularization of diabetic patients, we compared the outcomes for RA and RITA grafts to the circumflex coronary., Methods: From January 1, 1995, to December 31, 2011, 908 consecutive diabetic patients underwent first-time, isolated CABG (99% on-pump), 659 with the RA and 502 with the RITA, respectively, in two affiliated hospitals. Data were prospectively collected, and late mortality was determined from the Social Security Death Index. Propensity matching, based on preoperative and operative variables, identified 202 matched pairs from each group., Results: Long-term survival was similar for matched patients. Mortality, myocardial infarction, reoperation for bleeding, stroke, sepsis, and renal failure were not significantly different between groups. However, deep sternal wound infection (p<0.035) and respiratory failure (p<0.048) favored the RA group, in which the total major adverse events were significantly fewer (p=0.002)., Conclusions: In diabetic patients undergoing multivessel revascularization with either RA or RITA grafts to the circumflex coronary, long-term survival is similar. However, RA patients experienced significantly fewer respiratory or sternal wound adverse events. The RA is the preferred conduit to extend to more diabetic patients the recognized survival benefit of a multiple arterial graft strategy., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Coronary artery fistulae are uncommon, reported in 0.25% of patients undergoing coronary angiography. Two patients with congenital coronary artery fistula and coronary artery disease who presented with symptoms of exacerbated congestive heart failure out of proportion to their atherosclerotic burden were successfully treated by epicardial fistula ligation and coronary artery bypass grafting with marked improvement in functional status.

Background: A survival benefit of radial artery use versus saphenous vein grafting in coronary artery bypass grafting (CABG) has been reported. We aimed to elucidate the relative radial artery survival benefit as a function of time after surgery from two independent CABG series., Methods: We compared 0- to 15-year survival with radial artery versus saphenous vein grafting in isolated, nonsalvage primary CABG with left internal thoracic artery to left anterior descending from two institutions: Ohio (radial artery [n=2,361; 61 years]; saphenous vein [n=2,547; 67 years]), and New York (radial artery [n=1,970; 58 years]; saphenous vein [n=2,974; 69 years]). Separate multivariate radial artery-use propensity models based on demographic, preoperative factors, intraoperative variables, and completeness of revascularization data were computed and used to derive propensity- and sex-matched CABG cohorts (1,799 [Ohio] and 995 [New York] pairs). A three-phase (early and late) mortality model was fit to Kaplan-Meier mortality estimates and used to derive relative radial artery versus saphenous vein hazard functions., Results: Radial artery use patterns and patient risk profiles differed substantially for New York and Ohio, with the New York radial artery cohort significantly younger and more male. Within-institution matched graft-type cohorts were well matched. Cumulative mortality was significantly better for radial artery at both institutions (p < 0.001 both). All mortality-time data were well described by the three-phase model, and the derived relative hazard functions were qualitatively and quantitatively similar for New York and Ohio, exhibiting maximal benefit between 0.5 and 5 years., Conclusions: Despite substantial differences in radial artery use patterns during a 15-year period, our analysis in large propensity-matched radial artery and saphenous vein cohorts yielded remarkably similar, time-varying radial artery to saphenous vein survival benefit at both institutions. These converging findings based on two independent patient series extend currently available objective evidence in support of a radial artery survival advantage in CABG., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Liposarcoma occurs very rarely in the mediastinum. Patients often remain asymptomatic until it grows large enough to cause direct invasion or compression of adjacent organs. We report a case of a 77-year-old male presented with dyspnea of exertion and was found to have a large mediastinal mass which was eventually diagnosed as primary mediastinal well-differentiated liposarcoma. The limited respiratory function at the initial presentation prompted phrenic nerve preserving incomplete resection rather than radical removal of the adjacent mediastinal structures. After surgical removal, the recurrence for well-differentiated mediastinal liposarcomas in the mediastinum is unknown; therefore, close follow-up is crucial.

Objective: We sought to determine if the radial artery (RA) or the free right internal thoracic artery (RITA) is the better conduit to bypass the circumflex coronary artery during coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA)., Methods: Propensity matching was performed on 2488 CABG-LITA patients from 2 affiliated centers, resulting in 528 pairs who received either a RA at one center or a free RITA at the other center to bypass the circumflex coronary artery from 1995 to 2009., Results: Kaplan Meier estimated 1-, 5-, 10-, and 15-year survival rates were 99%, 95%, 85%, and 76% for RA patients, respectively, and 97%, 92%, 80%, and 71% for RITA patients, respectively (P = .060). Major adverse events (MAEs) were fewer in the RA group (7.6% vs 14.0%; P = .001) and use of the RA was a significant predictor of reduced MAEs (odds ratio [OR], 0.48; P = .002) in all patients and especially in diabetic (OR, 0.32; P = .003), older (OR, 0.40; P = .009), obese (OR, 0.15; P < .001), and chronic obstructive pulmonary disease (COPD) (OR, 0.05; P = .016) patients. However, survival was better with RA only in COPD (hazard ratio, 0.49; P = .045) and older (hazard ratio, 0.71; P = .050) patients. Overall RA patency (83.9%) was similar to RITA patency (87.4%) at a mean of 5.1 ± 3.8 years (P = .155)., Conclusions: Long-term survival is similar in CABG-LITA patients using either a RA or free RITA graft to bypass the circumflex coronary artery. RA grafting has fewer MAEs, a similar patency to RITA, and improves survival in older and COPD patients. The choice of the second arterial conduit should be guided by patient profiles and surgeon preferences., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Radial artery (RA) grafting has a clear survival advantage after coronary artery bypass grafting (CABG) in studies with predominantly male populations, but the impact on women's long-term survival is unclear. We sought to determine if the reported long-term survival benefit of RA versus saphenous vein (SV) grafting in the general CABG population is valid for women., Methods: Between 1995 and 2010, 1339 female patients were alive 30 days after primary, isolated CABG with left internal thoracic artery (LITA) and additional RA or SV conduits as needed. Patients were evaluated based on RA use: 332 patients had RA and 1007 patients had SV. Of these, 283 RA patients were matched to SV counterparts using a nonparsimonious propensity model based on 45 patient variables., Results: Kaplan-Meier estimated survivals for the matched RA women at 1, 5, 10, and 15 years were 99%, 93%, 80%, and 70% versus 97%, 87%, 72%, and 58% for the SV women (log rank, P = .018). For symptomatic patients, overall RA patency was 80%, which was not different from the LITA patency rate of 84% but was superior to the SV conduits patency rate of 56% (P < .001)., Conclusions: In women undergoing CABG with LITA grafting, use of an RA graft improves survival compared with use of an SV graft., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Left atrial dissection (LatD) is a rare entity most commonly associated with mitral valve surgery. We have reviewed our experience with 4 patients to better define the etiology and the treatment of LatD., Methods: From 1991 to 2012, 4 patients experienced LatD after surgery (1 of 6,302, or 0.02%, of isolated coronary artery bypass grafting patients and 3 of 1,895, or 0.16%, of mitral valve patients). Patient and perioperative data and management were reviewed., Results: Two patients were women, and ages ranged from 49 to 80 years. Three patients underwent mitral procedures (two replacements with coronary artery bypass grafting and one repair) for mitral regurgitation. One patient underwent emergent isolated coronary artery bypass grafting after cardiopulmonary resuscitation for a left main dissection during percutaneous coronary intervention. Three LatDs were found during surgery, and one LatD was found 12 days after mitral repair and was successfully treated nonoperatively. The LatD was located along the posterior atrial wall originating from the atrioventricular junction in all cases and obstructed mitral valve inflow. Operative repair focused on the evacuation of hematoma, obliteration of the false lumen, and repair of the entry injury. No mortality occurred., Conclusions: Left atrial dissection is a rare complication of cardiac surgery, probably related to a contained atrioventricular separation allowing pressurized blood to separate the layers of the posterior left atrium. Prompt intraoperative diagnosis, obliterating the false cavity, and addressing the entry point are essential. In contrast, a nonoperative approach in a stable patient with a delayed LatD suggests healing of the dissection, and atrial remodeling occurs., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Diabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA., Methods: A propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010., Results: We compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/- SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122]., Conclusion: For diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined.

A second recurrence of an excised nonfamilial cardiac myxoma is rare. Myxomatous cerebral aneurysms as a complication of cardiac myxomas are equally rare. A unique case of a patient with a total of 4 myxomas over a 20-year interval is presented. Her most recent presentation was a second recurrence of a left atrial myxoma, a de novo right atrial myxoma, and multiple cerebral myxomatous aneurysms. The challenging reconstruction of the normal anatomy was achieved with the use of porcine extracellular matrix patches. A diagnostic cerebral angiogram was later performed, and the aneurysms will be monitored for growth and possible intervention.

Background: We sought to examine the effect of different conduits on the progression of atherosclerosis in previously revascularized coronary territories., Methods: Between 1995 and 2010, 4,960 patients were discharged alive after primary isolated coronary artery bypass grafting (CABG) with a left internal thoracic artery (LITA) conduit and additional conduits as needed: radial artery (RA) or saphenous vein graft (SVG), or both. Seven hundred seventy-two patients had coronary angiography for recurrent symptoms an average of 5.5±3.5 years after CABG (range, 0.1-16 years). Cumulative graft patency and disease progression in the native vessels was estimated by the Kaplan-Meier survival method. The log-rank test was used to assess differences of disease progression per territory between different types of conduits., Results: Kaplan-Meier-estimated 1-, 5-, and 10-year overall disease progression in territories with patent LITAs was 0.01%, 4%, and 8%, respectively; with patent RA grafts, it was 0.01%, 6%, and 11%, respectively (log-rank test, p=0.157); and with patent SVGs it was 3%, 19%, and 43%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries in the anterior territory with patent LITA-to-left anterior descending (LAD) artery was 8%, and with patent RA grafts versus patent SVGs to the diagonal branches of LAD artery was 10% and 40%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries to the lateral territory with a patent RA graft was 11% versus 50% with a patent SVG (log-rank test; p<0.0001)., Conclusions: RA and LITA grafting has a strong protective effect against progression of native coronary artery disease in previously grafted vessels. Multiple arterial grafting may improve long-term survival by preventing progression of atherosclerosis in the native coronary vessels., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The second best conduit for coronary artery bypass graft surgery (CABG) is unclear. We sought to determine if the use of a second arterial conduit, the radial artery (RA), would improve long-term survival after CABG using the left internal thoracic artery (LITA) and saphenous vein (SV)., Methods: We compared the 14-year outcomes in propensity-matched patients undergoing isolated, primary CABG using the LITA, RA, and SV versus CABG using the LITA and only SV. In all, 826 patients from each group had similar propensity-matched demographics and multiple variables. The primary endpoint was all-cause mortality obtained using the Social Security Death Index., Results: Perioperative outcomes including in hospital mortality (0.1% for the RA patients and 0.2% for the SV patients) were similar. Kaplan-Meier survival at 1, 5, and 10 years was 98.3%, 93.9%, and 83.1% for the RA group versus 97.2%, 88.7%, and 74.3% for the SV group (log rank, p = 0.0011). Cox proportional hazards models showed a lower all-cause mortality in the RA group (hazard ratio 0.72, confidence interval: 0.56 to 0.92, p = 0.0084). Ten-year survivals showed a 52% increased mortality for the SV patients (25.7%) versus the RA patients (16.9%; p = 0.0011). For symptomatic patients, RA patency was 80.7%, which was not different than the LITA patency rate of 86.4% but was superior to the SV patency rate of 46.7% (p < 0.001)., Conclusions: Using the LITA, SV, and a RA conduit for CABG results in significantly improved long-term survival compared with using the LITA and SV. The use of two arterial conduits offers a clear and lasting survival advantage, likely due to the improved patency of RA grafts. We conclude that RA conduits should be more widely utilized during CABG., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A case of large cardiac myxoma associated with primary B cell lymphoma is described in a patient presenting with acute obstructive left heart failure. Emergent surgical removal was performed along with mitral valve repair., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To assess the full root modification of the Ross procedure, we examined operative and long-term results., Methods: We retrospectively reviewed 145 patients (118 men and 27 women) operated on from March 1987 through April 1997. Ages ranged from 17 to 68 years. Primary diagnosis was aortic stenosis in 43 patients (29.6%) and aortic regurgitation in 62 patients (42.8%). There was mixed disease (stenosis and regurgitation) in 40 patients (29.6%) of whom the vast majority had predominant stenosis., Results: Early death was 7 of 145 patients (4.8%). Twelve patients had 14 significant complications (8.5%). There were four late deaths. Overall patient survival is 90.5% +/- 3.1% at 5 years and 84.5% +/- 14.1% at 7 years. Endocarditis occurred in three patients-two on the autograft and one on the pulmonary homograft. Three patients had cerebrovascular accidents. In 5 of 132 patients (3.8%) reoperations were required on the autograft. Freedom from autograft reoperation was 93.9% +/- 3.1% at 5 years and 88.6% +/- 6.4% at 7 years. Echocardiographic follow-up reveals more than mild aortic regurgitation in only nine patients, including the five patients in whom reoperations were required. Seven of 11 patients with active endocarditis at the time of the operation had adverse outcomes., Conclusions: Ten years' experience with the modified Ross procedure has shown excellent results with regard to short- and long-term morbidity and death. It is the procedure of choice for young patients who need aortic valve replacement but should be used with caution in the setting of active endocarditis.

Retinal artery embolization is an unusual but serious complication of calcific aortic stenosis. However, it is rare for retinal embolization to be the presenting feature of aortic stenosis. This report describes a young patient who presented with an acute retinal artery occlusion secondary to calcific aortic valve disease, and discusses the rationale for early surgical intervention.

A 43-year-old woman with a history of cutaneous granular cell tumor presented with severe aortic regurgitation due to a type A aortic dissection. During repair, multiple masses were found on the surface of the heart, which later were identified to be granular cell tumor. We present an extremely rare case of multicentric granular cell tumor of the skin and heart, manifested over a 23-year period.

Aneurysms of the left ventricle may be congenital or may occur after a myocardial infarction, trauma, or endocarditis. Infective endocarditis can cause destructive injury to the heart in various ways. This report describes the formation of an aneurysm of the left ventricle from trauma of a bacterial vegetation of the mitral valve. Early recognition by echocardiography and magnetic resonance imaging led to successful repair and prevented a catastrophic result.

Continuous povidone-iodine irrigation is frequently used to treat mediastinitis after median sternotomy and has been considered safe and effective. We describe a 34-month-old patient with mediastinitis after median sternotomy who was treated with continuous povidone-iodine irrigation and who absorbed toxic quantities of iodine (total serum iodine, 9,375 micrograms/dl; normal range, 4.5 to 9.0 micrograms/dl). An unexplained metabolic acidosis developed, along with changes in mental status, and the patient died. This experience and a thorough review of the literature lead us to believe that continuous povidone-iodine irrigation of the mediastinum is contraindicated.

The optimal method of anticoagulation in children with mechanical heart valves is controversial. Between 1975 and 1986, aspirin or aspirin with dipyridamole has been used for anticoagulation in children receiving a mechanical aortic valve at the University of California, San Francisco. Fifty-one patients (ages 1 to 23 years, mean 12.9 years) were treated with aspirin (n = 45) or aspirin with dipyridamole (n = 6) and observed a mean of 36.5 months (range 3 to 100 months). There were four late deaths: two from endocarditis and two from other medical problems, but none related to thrombosis or embolus. Follow-up was accomplished by direct contact with the patient, parent, or referring physician. Two patients (3.9%) were lost to late follow-up. One minor neurologic event occurred perioperatively and resolved spontaneously. There were no postoperative thromboembolic events. Eleven asymptomatic children were recently studied by magnetic resonance imaging or computed axial tomography of the brain and had no evidence of prior silent cerebral thromboembolic defects. There were four patients (5.9%) who had minor hemorrhagic complications: Three patients had nosebleeds and one patient had an upper gastrointestinal hemorrhage. Five patients were changed to warfarin anticoagulation: the patient with upper gastrointestinal hemorrhage and four older patients because of physician preference, all after uncomplicated aspirin therapy. There were no mechanical valve failures, although one patient required reoperation 9 months later for perivalvular leak. All children have remained in normal sinus or paced rhythm during follow-up. These results show that children with mechanical aortic valves in normal sinus rhythm can be safely treated with aspirin (or aspirin with dipyridamole) with little risk of thromboembolic events, valve thrombosis, or valve failure. Hemorrhagic complications resulting from aspirin are minor and easily treated.