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Abstract Background Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient. Case presentation A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14x7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts. The patient was discharged on the 9th postoperative day. Conclusion This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.

Background-Titin represents an important biomechanical sensor which determines compliance and diastolic/systolic function of the left ventricle (LV). To assess the different titin-isoform expression and the relationships with functional and geometric patterns, we analyzed titin-isoform expression and cardiomyocytes contractile function in myocardial biopsy samples of patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS) and for aortic regurgitation (AR). Method -Specimens, collected from the LV of 35 with AS and 35 with AR undergoing AVR were analyzed for titin-isoform expression and cardiomyocytes force measurement. Ten donor hearts were analyzed as controls for normal values. Results were implemented with preoperative geometry and function assessed by Doppler echocardiography. Results-Compared to controls, N2BA/N2B titin-isoforms ratio was reduced to 0.24 in AS (p < 0.001) but increased to 0.51 in AR (p < 0.001). N2BA/N2B titin-isoforms ratio was further reduced in 8 patients with severe (restrictive) diastolic dysfunction (0.17 ± 0.03, p < 0.001) but was increased in patients with severe systolic dysfunction (0.58 ± 0.07, p < 0.001). As compared to controls, Fpasive was higher in AS (6.7 ± 0.2 vs 4.4 ± 0.4 kN/m 2 , p < 0.001) but was lower in AR (3.7 ± 0.2 vs 4.4 ± 0.4 kN/m 2 , p < 0.001). Total force was comparable. Fpassive was significantly higher in AS patients with severe than with moderate LV diastolic dysfunction (7.1 ± 0.5 vs 6.6. ± 0.6, p = 0.004). Conclusions-titin-isoform expression differs in AS and AR as adaptive response to different pathophysiologic scenarios. Co-expressing isoforms at varying ratios results in modulation of the passive mechanical behavior of the LV at different degree of dysfunction and allows for compensative adjustment of the diastolic/systolic properties of the myocardium., (Copyright © 2018. Published by Elsevier B.V.)

Background: Severe prosthesis-patient mismatch (PPM) is considered to further decrease survival compared to moderate PPM. This study aimed to assess the impact of severe PPM on survival after aortic valve replacement (AVR)., Methods: We retrospectively studied 2404 consecutive patients with PPM who underwent first-time AVR for pure stenosis between January 2003 and December 2014. Mismatch was moderate for indexed effective valve orifice >0.65 to <0.85cm 2 /m 2 and severe for indexed effective valve orifice ≤0.65cm 2 /m 2 . Moderate mismatch occurred in 2165 patients (89%), and severe in 239 (11%) patients. Logistic multiple regression with bootstrapping and propensity score analyses were performed using 29 clinical and demographic data to assess the risk-adjusted impact of severe mismatch on mortality. The Cox proportional hazards model was constructed to process the long-term outcome., Results: Early mortality was 2.3% (51/2165) in moderate mismatch group and 3.7% (9/239) in severe mismatch group (p=0.2). Mortality at 5 and 10 years, was 218/1470 (14.8%) and 252/585 (43.1%) for moderate mismatch and 43/198 (21.7%) and 61/105 (58.1%) for severe mismatch (p=0.02 and p=0.006). Multivariable predictors of late mortality were as follows: age ≥70 years, left ventricular ejection fraction ≤40%, indexed left ventricular mass >220g/m 2 and concomitant coronary artery revascularization. After propensity score matching, conditional logistic regression analysis demonstrated no relationship between severe mismatch and increased mortality at 5 postoperative years (HR, 0.9; 95% CI, 0.7-1.6; p=0.06), whereas it was significant at 10 postoperative years (HR, 1.9; 95% CI, 1.2-2.5; p=0.03). During the follow-up, severe mismatch was associated with more frequent hospital readmissions for cardiac events (0.12 vs. 0.08 events/patient/year, p=0.007)., Conclusions: Patients with severe mismatch had lower long-term survival and higher incidence of hospital readmissions for cardiac events. However, the effect of severe mismatch on outcome appeared mainly related to the preoperative risk profile of each patient., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Aims: Statin pretreatment in patients undergoing cardiac surgery is understood to prevent postoperative atrial fibrillation (AF). However, this is based on observational and limited randomized trial evidence, resulting in uncertainty about any genuine anti-arrhythmic benefits of these agents in this setting. We therefore aimed to quantify precisely the association between statin pretreatment and postoperative AF among patients undergoing cardiac surgery., Methods and Results: A detailed search of MEDLINE and PubMed databases (1st January 1996 to 31st July 2012) was conducted, followed by a review of the reference lists of published studies and correspondence with trial investigators to obtain individual-participant data for meta-analysis. Evidence was combined across prospective, randomized clinical trials that compared the risk of postoperative AF among individuals randomized to statin pretreatment or placebo/control medication before elective cardiac surgery. Postoperative AF was defined as episodes of AF lasting ≥5 min. Overall, 1105 participants from 11 trials were included; of them, 552 received statin therapy preoperatively. Postoperative AF occurred in 19% of these participants when compared with 36% of those not treated with statins (odds ratio 0.41, 95% confidence interval 0.31-0.54, P < 0.00001, using a random-effects model). Atrial fibrillation prevention by statin pretreatment was consistent across different subgroups., Conclusion: Short-term statin pretreatment may reduce the risk of postoperative AF among patients undergoing cardiac surgery., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Objectives: Composite grafts allow complete arterial revascularization with minimal aortic manipulations. The Y-T configuration supplies all distal branches adequately, whereas it is unclear whether complex composite configurations (K, Π or double-Y) are equally at rest or when challenged by maximal requirements., Methods: Forty-seven patients who underwent off-pump coronary artery revascularization by multiple arterial composite grafts (K, Π or double-Y) were retrospectively evaluated. Indication for this surgical option was porcelain aorta or conduit unavailability. Composite systems were evaluated by intraoperative flow measurements and perioperative transthoracic Doppler ultrasonography, 12 months later also by exercise test, sestamibi scintigraphy at rest and during induced hyperaemia and by 64-slice multidetector CT angiography., Results: A total of 141 distal anastomoses were implanted as composite grafts. Perioperative flow measurements and 12-month Doppler ultrasonography were adequate at rest. At stress test, chest pain and/or induced ECG evidence of ischaemia are found in 16 patients (39%). During dipyridamole-induced hyperaemia, single-photon emission computed tomography image revealed that mean summed stress score was 7.2 ± 5.7, summed difference score 5.3 ± 4.2 and coronary flow reserve 1.7 ± 0.2., Conclusions: Multiple composite grafts, albeit adequate at rest, were unable to meet flow requirements during maximal hyperaemia. In daily practice, their use must be not a choice but rather a necessity in those patients without alternative options., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: We aimed to support the structural and functional distinction between aortic stenosis (AS) and aortic regurgitation (AR)., Methods: Biopsy specimens taken from 70 selected patients (35 with AS and 35 with AR) undergoing aortic valve replacement (AVR) were analyzed for their cardiomyocyte dimensions and structure, interstitial fibrosis and contractile function. To determine normal values of contractile function, 10 donor hearts were analyzed., Results: Cardiomyocyte diameter was higher in AS than in AR (22.7 ± 2.2 vs. 13.2 ± 0.7 µm, p < 0.001). Length was higher in AR (121.2 ± 9.4 vs. 95.6 ± 3.7 µm, p < 0.001). Collagen volume fraction was increased in both AS and AR, but was lower in the AS specimens (7.7 ± 2.3 vs. 8.9 ± 2.3, p = 0.01). Myofibril density was reduced in AR (38 ± 4 vs. 48 ± 5%, p < 0.001). Cardiomyocyte diameter and length were closely linked to the relative left ventricular (LV) wall thickness (R 2 = 0.85, p < 0.001 and R 2 = 0.68, p = 0.003). The cardiomyocytes of AS patients had higher F passive (6.6 ± 0.3 vs. 4.6 ± 0.2 kN/m 2 , p < 0.001), but their total force was comparable. F passive was also significantly higher in AS patients with restrictive rather than pseudo-normal LV filling (7.3 ± 0.5 vs. 6.7 ± 0.6, p = 0.004). In AS patients, but not in AR patients, F passive showed a significant association with the cardiomyocyte diameter (R 2 = 0.88, p < 0.001 vs. R 2 = 0.31, p = 0.6)., Conclusions: LV myocardial structure and function differ in AS and AR, allowing for compensative adjustment of the diastolic/systolic properties of the myocardium. © 2015 S. Karger AG, Basel.

Objectives: A history of percutaneous coronary intervention increases the risk of death and complications of coronary artery bypass grafting. This retrospective multicenter study evaluated the impact of continuative use of statin on postoperative outcomes when subsequent elective coronary artery bypass grafting is required after percutaneous coronary intervention., Methods: Among 14,575 patients who underwent isolated first-time coronary artery bypass grafting between January 2000 and December 2010, 2501 who had previous percutaneous coronary intervention with stenting and fulfilled inclusion criteria were enrolled. Continuative statin therapy was used in 1528 patients and not used in 973 patients. Logistic multiple regression and propensity score analyses were used to assess the risk-adjusted impact of statin therapy on in-hospital mortality and major adverse cardiac events. The Cox proportional hazards model was constructed to assess the effect of continuative statin therapy on 24-month outcome., Results: At multivariate analysis, age more than 70 years, 3-vessel or 2-vessel plus left main coronary disease, multivessel percutaneous coronary intervention, ejection fraction 0.40 or less, diabetes mellitus, and logistic European System for Cardiac Operative Risk Evaluation 5 or greater were independent predictors of hospital mortality and major adverse cardiac events. After propensity score matching, conditional logistic regression analysis demonstrated that continuative statin therapy before coronary artery bypass grafting reduced the risk for hospital and 2-year mortality (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.12-0. 57; P=.004 and OR, 0.6; 95% CI, 0.36-0.96; P=.04, respectively) and major adverse cardiac events (OR, 0.31; 95% CI, 0.18-0.78; P=.003 and OR, 0.5; 95% CI, 0.34-0.76; P=.006, respectively)., Conclusions: Long-term statin treatment after percutaneous coronary intervention improves early and midterm outcome when surgical revascularization will be required., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: An increasing number of patients presenting for urgent coronary surgery have been exposed to clopidogrel, which constitutes a risk of bleeding and related events. Based on the wide variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case-control study., Methods: Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated with clopidogrel and prospectively underwent a strategy guided by platelet function testing. Outcomes were compared with 2 propensity score matched groups: group B underwent CABG after the currently recommended 5 days without clopidogrel; group C were never exposed to clopidogrel., Results: Patients in group A had reduced postoperative bleeding compared with those in group B (523±202 mL vs 851±605 mL; P<.001) and a lower number of units packed red blood cells (PRBCs) transfused during the postoperative hospital stay (1.2±1.6 units vs 1.9±1.8 units; P=.004). Postoperative bleeding and the number of units of PRBCs transfused were similar in group A and group C. There was no difference in blood-derived products and platelet consumption, mortality, or the need for reoperation among the groups. Patients in group A waited 3.6±1.7 days for surgery. The strategy used for group A saved 280 days of hospital stay in total., Conclusions: The strategy guided by platelet function testing for off-pump CABG offers improved guidance for optimal timing of CABG in patients treated with clopidogrel. This strategy significantly reduces postoperative bleeding and blood consumption, and has a shorter waiting time for surgery than current clinical practice., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This retrospective cohort study investigated the functional and haemodynamic mid-term results over 3-years follow up of the left internal mammary artery (LIMA) conduit in composite Y-graft configuration with radial artery (RA) in a population of patients who underwent off-pump coronary artery bypass grafting (CABG)., Methods: 148 patients who underwent off-pump CABG with composite Y-graft, were evaluated over 3-year follow up. Two-day dipyridamole induced maximal hyperaemia/rest 99mTc-sestamibi was scheduled preoperatively and 36 months after surgery for functional evaluation. Morphological evaluation was performed by 64 slice multidetector computed tomography (CT) 36 months after surgery., Results: Clinical adverse events were rare within 3 years follow up. Minimal to severe scintigraphic evidence of stress induced ischaemia occurred in 24 patients. Left ventricular (LV) hypertrophy (HR 3.1; 95% CI, 1.5-9.3; p = 0.01) and poor coronary run off (HR 4.1; 95% CI, 2.1-10.8; p = 0.005) were significant multivariate predictors of reversible stress induced ischaemia. 64 slice multidetector CT showed that the main stem of Y composite grafts was patent in all patients, while distal LIMA or RA was stenosed or occluded in 9 patients., Conclusion: Composite Y-graft was adequate to meet the flow requirements of target coronary artery either at rest or during maximal hyperaemia. The use of Y-graft should be carefully evaluated in patients with LV hypertrophy and/or poor coronary run-off., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

OBJECTIVES Left ventricular (LV) diastolic dysfunction after aortic valve replacement (AVR) carries a substantial risk of development of heart failure and reduced survival. In addition to echocardiography, B-type natriuretic peptide (BNP) provides a powerful incremental assessment of diastolic function. This study evaluates BNP as a marker of LV diastolic dysfunction in a cohort of patients with preserved LV ejection fraction who underwent AVR for pure aortic stenosis and the relationship between BNP values and the grade of LV diastolic dysfunction. METHODS A total of 113 patients were included in the study. Echocardiographic evaluation was performed preoperatively, 5 days postoperatively and at 12-month follow-up, to assess LV dimensional and functional parameters. Diastolic function was labelled as normal, mild, moderate or severe dysfunction. Concomitantly, BNP levels were evaluated. RESULTS Mild to severe diastolic dysfunction occurred preoperatively in all patients. At 12-month follow-up, 65 (62.5%) patients had mild and 25 (24.1%) moderate to severe diastolic dysfunction. BNP values, categorized for quartile distribution, correlated with diastolic dysfunction grade (P<0.001 for each comparison). At receiver operating characteristic analysis, the BNP level of 120 pg/ml was 91% sensitive and 85% specific for diastolic disease, while 300 pg/ml was 80% sensitive and 91% specific for moderate or severe diastolic dysfunction. Twelve months after AVR, BNP values were strongly correlated with the significant echocardiographic parameters suggestive of diastolic dysfunction (P≤0.006 in all cases). CONCLUSIONS The BNP level following AVR is related to diastolic disease severity and may complement echocardiographic evaluation when symptoms are unclear and LV function is difficult to interpret.

Objective: Asymmetric septal hypertrophy frequently coexists with severe aortic stenosis and can be unmasked after successful aortic valve replacement (AVR), jeopardizing the clinical and echocardiographic results. The aim of our study was to investigate, at 5 years postoperatively, the effectiveness of myectomy associated with AVR on left ventricular (LV) mass regression and LV diastolic function., Methods: From 1997 and 2004, 86 patients with a diagnosis of severe aortic stenosis and asymmetric septal hypertrophy consecutively underwent AVR (group A) or AVR and concomitant myectomy (group B). To assess the improvement in LV mass and LV diastolic function, we studied the 52 survivors (23 in group A and 29 in group B) who had the same prosthesis type (beleaflet mechanical), the same size (21 mm), and the same follow-up length., Results: In group A, the LV mass index regressed from 119.2 ± 22.0 to 113.8 ± 21.8, and in group B, it regressed from 121.6 ± 20.8 to 112.7 ± 20.0 (P < .0005). In group A, the E/E' ratio improved from 15.3 ± 3.0 to 11.8 ± 3.0, and in group B, it improved from 16.2 ± 3.2 to 12.1 ± 3.3 (P = .02)., Conclusions: Surgeons should inspect the LV outflow tract at AVR. Concomitant myectomy at AVR is a safe and effective procedure that improves LV mass regression and LV diastolic function., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The development of intimal hyperplasia and graft failure is an important problem in cardiac surgery. A fundamental process in intimal hyperplasia is the degradation of extracellular matrix by metalloproteases which induces the vascular smooth-muscle cells migration and sets the scene for graft atherosclerosis. This study investigated whether doxycycline, a metalloproteases inhibitor, can prevent the intimal hyperplasia occurrence in cultured human internal mammary artery, thus extending graft patency., Methods: Segments of internal mammary artery from 20 consecutive patients were prepared and cultured for 2 weeks in serum-supplemented medium (control) or in medium supplemented with 10⁻⁵  M and 10⁻⁶ M doxycycline concentrations. Tissues were fixed, sectioned, and stained, and neointimal thickness was measured by computer-aided image analysis. Further sections were cultured and prepared for gel enzymography to measure the matrix metalloproteinase-2 and -9 levels., Results: At the end of the culture period, neointimal thickness was significantly (P = 0.001) dose-dependently reduced in samples treated with doxycycline when compared with controls. Gelatin enzymography demonstrated a reduction in values for both latent and active forms of metalloproteases., Conclusions: Doxycycline, in a model of internal mammary artery intimal hyperplasia, has a specific role in inhibiting metalloproteases activity and may prevent graft stenosis.

Background: After coronary artery bypass graft surgery, older women have less favorable clinical outcome and lower conduit patency compared with men. This less favorable outcome can be in part ascribed to impaired endothelium-derived nitric oxide (eNOS) production. This study evaluated endothelial nitric oxide synthase expression in internal mammary artery from postmenopausal women undergoing coronary artery bypass graft surgery., Methods: Internal mammary artery segments were obtained from 20 postmenopausal woman and 20 matched male patients. Twenty more segments from younger patients were used as controls. Expression of eNOS messenger RNA in internal mammary artery endothelial cells were evaluated by polymerase chain reaction and real-time quantitative reverse transcription polymerase chain reaction. The eNOS protein level was assayed by Western blot. Vascular dynamics of specimens were evaluated by organ chamber methodology., Results: In postmenopausal women, the band of messenger RNA for eNOS was reduced by 37.4% and by 25.2%, respectively, compared with matched men and the control group (62.6%±4.8% versus 74.8%±5.3%, p<0.001). In comparison with the control group lane, the eNOS protein immunoreactive band was 44.2% decreased in postmenopausal women and 34.5% decreased in matched men, and was significantly decreased in postmenopausal women as compared with matched men (55.8%±4.6% versus 65.5%±5.2%, p<0.001). Nitric oxide-mediated vasomotor dynamics were consistent with reduced eNOS production., Conclusions: Internal mammary artery endothelial cells from women after menopause undergoing coronary surgery have impaired expression of messenger RNA for eNOS and reduced eNOS levels. Reduced bioactivity of nitric oxide translates into impaired endothelial metabolism that could contribute to worse surgical outcome., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This multicenter study investigated the impact of previous percutaneous coronary interventions (PCI) on postoperative outcome and 5-year survival of subsequent coronary artery bypass grafting., Methods: Among 7,855 patients who underwent isolated first-time coronary artery bypass grafting between January 2000 and December 2005, 6,834 (87%) had no previous PCI and 1,021 (13%) had previous PCI with stenting. Logistic multiple regression and propensity score analyses were used to assess the risk-adjusted impact of prior PCI on in-hospital mortality and major adverse cardiac events. The Cox regression model was used to assess the effect of prior PCI on 3-year and 5-year survival., Results: After risk-adjusted multivariate analysis, age over 70 years, female sex, 3-vessel or 2-vessel plus left main coronary disease, multivessel PCI, ejection fraction 0.40 or less, diabetes mellitus, previous myocardial infarction, and chronic obstructive pulmonary disease were identified as independent predictors of both hospital mortality and major adverse cardiac events. After propensity score matching, conditional logistic regression analysis identified history of previous PCI as significantly associated with an increased risk for hospital mortality (odds ratio, 2.8; 95% confidence interval 1.4 to 4.8; p=0.003) and major adverse cardiac events (odds ratio 2.1; 95% confidence interval 1.2 to 3.6; p<0.001). Survival at 3 and 5 years was lower in patients with previous PCI compared with the no-PCI patients (97.4%±0.01% vs 96.5%±0.02% and 94.2%±0.03% vs 92.1%±0.05%; log-rank test: p=0.03)., Conclusions: Our results provided further evidence that history of PCI before coronary artery bypass grafting increases risk of both operative death and perioperative complications, and decreases survival at 5 years follow-up., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Aortic valve replacement leads to improvement of coronary flow but not to complete normalization. Coronary hypoperfusion contributes to higher left ventricular mass persistence, arrhythmias, congestive heart failure and sudden death. This prospective study compares 2 similarly sized aortic prostheses (mechanical and porcine) regarding coronary flow and hemodynamic performances in patients who underwent surgery for pure aortic stenosis., Methods: Sixty patients having undergone aortic valve replacement for pure aortic stenosis with Medtronic Mosaic Ultra bioprosthesis 21 mm (n = 30) or St Jude Regent mechanical valve 19 mm (n = 30) were evaluated preoperatively and 12 months postoperatively comparing the coronary flow and the hemodynamic behavior. Echocardiography and cardiac positron emission tomography were performed at rest and during exercise or adenosine maximal stimulation, respectively., Results: The St Jude Regent mechanical valve, compared with the Medtronic Mosaic Ultra bioprosthesis, had reduced coronary flow reserve (2.1 ± 0.3 vs 2.3 ± 0.2; P = .003), less favorable systolic/diastolic time ratio (0.87 ± 0.02 vs 0.78 ± 0.03; P < .001), and higher mean transprosthetic gradient (46 ± 11 vs 38 ± 9; P = .003) during exercise. Multivariate analysis of impaired coronary reserve related indexed effective orifice area less than 0.65 cm/m(2) (risk ratio [RR], 1.9; 95% confidence intervals [CI], 1.5-2.8; P < .001), mechanical valve (RR, 2.5; 95% CI, 1.7-3.3; P < .001), and systolic/diastolic time ratio greater than 0.75 (RR, 2.6; 95% CI, 1.8-3.8; P < .001), as well as high transprosthetic gradient (RR, 1.7; 95% CI, 1.3-2.4; P < .001) ) during exercise with coronary reserve less than 2.2., Conclusions: Improvement of coronary flow and reserve was more evident for bioprostheses than for mechanical valves. The bioprostheses demonstrated superior hemodynamics during exercise, which may have some impact on exercise capability during normal daily life., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Prophylactic intraaortic balloon pump (IABP) support showed better outcomes in critical patients undergoing coronary revascularization compared with intraoperative or postoperative insertion. We conducted a prospective, randomized study to determine the optimal timing for preoperative IABP insertion in high-risk patients undergoing off-pump coronary artery revascularization., Methods: The study enrolled 230 consecutive high-risk patients (having a logistic European System for Cardiac Operative Risk Evaluation score of ≥10) undergoing off-pump coronary artery revascularization. They were randomized for preoperative IABP starting at 2 hours (2T, n=115) or 12 hours (12T, n=115). Clinical, biochemical, and hemodynamic results, and the need for inotropic drug support, were markers of outcome and compared between groups., Results: Hospital mortality in group 12T was reduced by 60%, but the difference between groups was not statistically significant (hazard ratio, 0.4; 95% confidence interval, 0.1 to 1.5; p=0.1). Twelve hours of preoperative IABP therapy reduced postoperative low output syndrome (hazard ratio, 0.4; 95% confidence interval, 0.1 to 0.9; p=0.03) and biomarker leakage upper normal limit (hazard ratio, 0.3; 95% confidence interval, 0.1 to 0.7; p=0.001). Postoperative left ventricular function was similar between the groups. Group 2T patients required higher inotropic support for a longer average duration and prolonged postoperative intensive care unit and hospital length of stay., Conclusions: Twelve hours preoperative IABP therapy improved treatment efficacy. Postoperative morbidity was reduced, but hospital mortality rate was not affected. The IABP-related complication rate was low and not related to the length of treatment., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study evaluated the impact of patient-prosthesis mismatch on myocardial function and high-energy phosphate metabolism after aortic valve replacement for pure aortic stenosis. Patients with and without patient-prosthesis mismatch were compared using magnetic resonance techniques., Methods: Thirty patients who had undergone aortic valve replacement with Medtronic Mosaic bioprosthesis were evaluated. Fifteen patients with patient-prosthesis mismatch were compared to 15 matched patients without patient-prosthesis mismatch. These two homogeneous groups were studied for myocardial metabolism and left ventricle function preoperatively and at 12 months postoperatively with magnetic resonance imaging and (31)P spectroscopy., Results: All patients experienced improvement in myocardial metabolism and left ventricle function. Left ventricle mass regression was impaired in both groups. Impaired diastolic filling was associated with increased left ventricle wall mass in both groups (patient-prosthesis mismatch: R(2) = -0.71, p = 0.002; no patient-prosthesis mismatch: R(2) = -0.88, p < 0.001). Myocardial phosphocreatine/adenosine triphosphate ratio revealed a modest correlation with left ventricle function as evaluated by early acceleration peak (patient-prosthesis mismatch: R(2) = 0.37, p = 0.03; no patient-prosthesis mismatch: R(2) = 0.17, p = 0.02) and early deceleration peak (patient-prosthesis mismatch: R(2) = 0.30, p = 0.01; no patient-prosthesis mismatch: R(2) = 0.39, p = 0.008). No significant correlation between the phosphocreatine/adenosine triphosphate ratio and left ventricle mass was found (patient-prosthesis mismatch: R(2) = 0.39, p = 0.6; no patient-prosthesis mismatch: R(2) = 0.40, p = 0.08)., Conclusion: Aortic valve replacement leads to early improvement of left ventricle function and myocardial metabolism in all patients regardless of the occurrence of patient-prosthesis mismatch.

Background: It is unclear whether composite Y-grafts can withstand the flow demand of the coronary system at rest and under stress. This study compared the graft flow and flow reserve of the left internal mammary artery (LIMA) intraoperatively and over a 2-year follow-up in single or composite Y-graft configurations using the radial artery (RA)., Methods: One hundred patients who underwent off-pump myocardial revascularization with a composite Y-graft (group 2) were compared with a homogeneous group of 100 patients treated with a single independent LIMA graft on the left anterior descending artery (LAD) (group 1). Intraoperative baseline flow and flow after adenosine infusion into the left ventricle were analyzed. Over a 2-year follow-up, noninvasive longitudinal evaluation of flow was carried out at rest and during maximal hyperemic response by transthoracic Doppler ultrasonography. Final functional evaluation was obtained through a 2-day stress/rest 99mTc-sestamibi myocardial perfusion single-photon emission computed tomographic scan., Results: The proximal LIMA in a Y-graft configuration showed adaptability to flow dynamics. It had a greater average peak velocity (p = 0.02), flow volume (p < 0.01), and diameter (p < 0.01) than independent single LIMA grafts. Distal flow at rest and during adenosine recruitment was similar between groups both intraoperatively and at all time points of the follow-up. No steal phenomenon occurred at rest, nor was it induced by adenosine in the Y-graft group. Exercise nuclear scintigraphy showed satisfactory exercise tolerance and no inducible significant perfusion defects in both groups., Conclusions: Left internal mammary artery Y-grafting with the RA is adequate for flow requirements of distal branches at rest and during maximal hyperemia and is able to adapt its dimension to flow demand. Optimal results for RA anastomoses are possible only in arteries with critical stenosis and of good size and quality., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aim: This study evaluated risk factors for dysfunction and failure of the bovine Contegra valved conduit for right ventricle outflow tract reconstruction., Methods: A total of 156 bovine jugular vein conduits were reviewed. Early and late mortality were evaluated. Seriate echocardiography was performed through the follow-up (mean 58±43.2 months, range 12 to 108 months), and risk factors and adverse events evaluation were analyzed by multivariate logistic regression., Results: Hospital mortality was 7% (11/156). The only independent predictor of early mortality were cardiopulmonary bypass time >120 minutes and age <1 year. Postoperative mean RV to PA gradient was 10.4±9.1 mm Hg, increased to 18.7±14.5 mm Hg during the follow-up. A late gradient >30 mm Hg was assessed in 22 patients (15.1%),while 12 patients developed conduit valve regurgitation greater than 2+ without evidence of aneurismal formation. All patients with right ventricular (RV) to left ventricular (LV) pressure ratio >0.6 had conduit valve regurgitation. Acquired distal conduit stenosis was observed only in 1 patient. Thirteen patient underwent conduit replacement, diameter ≤14 mm was the only independent risk factor for reoperation. All explanted conduits were free from calcification and valve leaflets were intact and pliable. The Contegra graft itself was never cause of adverse event., Conclusion: The Contegra conduit provided excellent results and freedom from calcification in a medium-term follow-up. Younger age at operation was associated with higher need of replacements for conduit patient mismatch due to patient growth.

Background: The preferential harvesting technique of the internal mammary artery has been periodically debated. This randomized study evaluated the flow outcome of the skeletonized versus pedicled left internal mammary artery., Methods: Two hundred patients undergoing surgery for left anterior descending coronary artery revascularization were enrolled and randomized to pedicled (n=100) or skeletonized (n=100) harvesting. Intraoperative baseline flow and post adenosine infusion into the left ventricle, hospital outcome, echocardiographic results, and troponin I leakage were analyzed. Noninvasive periodic evaluation of flow was carried out at rest and during intravenous adenosine infusion by transthoracic Doppler ultrasound, and was stratified according to the harvesting technique. Final angiographic evaluation was performed by 64-slice multidetector computed tomography., Results: Skeletonized left internal mammary arteries demonstrated better flow capacity at rest and during adenosine recruitment perioperatively and at all time points of follow-up. Troponin I leakage was significantly higher in the pedicled group (59 vs 42, p=0.02). Pedicled harvesting (hazard ratio [HR] 3.6, 95% confidence interval [CI] 2.5 to 6.9, p<0.001); indexed left ventricular mass greater than 150 g/m2 (HR 4.6, 95% CI 3.1 to 7.5, p<0.001); and baseline corrected thrombolysis in myocardial infarction frame count greater than 30 (HR 4.4, 95% CI, 3.8 to 7.2, p<0.001) were the most powerful multivariable predictors of graft flow reserve less than 2.0. Postoperative echocardiographic results and clinical and angiographic outcomes were comparable between the two groups., Conclusions: Skeletonization of the left internal mammary artery, beyond traditional proven advantages, provided significantly higher flow capacity and better graft flow reserve., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

From January 1976 through December 1987, 194 patients with a mean age of 43.3 +/- 13.7 years (range, 11 to 74 years) underwent double (mitral and aortic) replacement of native valves with 8 types of bioprostheses: Carpentier-Edwards, 127 valves; Hancock, 76 valves; Liotta-Bioimplant, 57 valves; Ionescu-Shiley, 53 valves; Vascor, 27 valves; Carpentier-Edwards Pericardial, 22 valves; Angell-Shiley, 20 valves; and Implamedic, 6 valves. Concomitant cardiac procedures were performed in 25 patients (12.8%). There were 18 operative deaths (9.27%). Our retrospective analysis was restricted to 352 bioprostheses implanted in the 176 patients who survived surgery and were considered at risk for valve tissue failure. The overall cumulative duration of follow-up was 1,174.1 patient-years (range, 1 to 13 years). The durations of follow-up for specific valves were: Carpentier-Edwards, 920.2 valve-years; Hancock, 383.8 valve-years; Liotta-Bioimplant, 310.2 valve-years; Ionescu-Shiley, 357.7 valve-years; Vascor, 131.2 valve-years; Carpentier-Edwards Pericardial, 52.0 valve-years; Angell-Shiley, 167.0 valve-years; and Implamedic, 31.0 valve-years. Thirty patients had thromboembolic accidents, for a linearized incidence of 2.5% per patient-year. At 13 years, the actuarial freedom from thromboembolic accidents was 85.8% +/- 10.7%. Nine patients had endocarditis, for a linearized incidence of 0.7% per patient-year. At 13 years, the actuarial freedom from endocarditis was 92.0% +/- 1.5%. Twenty-four patients had valve tissue failure, for a cumulative linearized incidence of 1.87% per valve-year. The cumulative actuarial probability of freedom from valve tissue failure was 78.6% +/- 3.7% at 10 years and 51.2% +/- 10.7% at 13 years. The 24 patients with valve tissue failure all underwent reoperation: 20 of these had double valve replacement, 3 had aortic valve replacement alone, and 1 had mitral valve replacement alone. The mean interval between initial valve implantation and reoperation was 66.9 +/- 28.8 months. At reoperation, the hospital mortality was 15.1% (5 patients). This study showed that the long-term results of valve implantation are not significantly influenced by either prosthesis design or material. Moreover, the incidence of degenerative change was similar in the aortic and mitral positions.