Objectives Less-invasive options are available for surgical treatment of multivessel coronary artery disease. We hypothesized that stenting combined with grafting of the left anterior descending ...artery with the left internal thoracic artery through a minithoracotomy (hybrid procedure) would provide the best outcome. Methods Patients with equivalent numbers of coronary lesions (2.8 ± 0.4) underwent either hybrid (n = 15) or off-pump coronary artery bypass through a sternotomy (n = 30). Early and 1-year outcomes were compared. Blood drawn from the aorta and coronary sinus immediately postoperatively was analyzed for activation of coagulation (prothrombin fragment 1.2 and activated Factor XII), myocardial injury (myoglobin), and inflammation (interleukin 8) by using an enzyme-linked immunosorbent assay. Target-vessel patency was determined by means of computed tomographic angiographic analysis. Results The hybrid procedure was associated with significantly shorter lengths of intubation and stays in the intensive care unit and hospital and perioperative morbidity ( P < .05). Intraoperative costs were increased but postoperative costs were reduced for the hybrid procedure compared with off-pump coronary artery bypass through a sternotomy. As a result, overall total costs were not significantly different between the groups. After adjusting for potential confounders, assignment to the hybrid group was an independent predictor of shortened time to return to work (t = −2.12, P = .04). Patient satisfaction after the hybrid procedure, as judged on a 6-point scale, was greater versus that after off-pump coronary artery bypass through a sternotomy. Finally, the hybrid procedure showed significantly reduced transcardiac gradients of markers of coagulation, myocardial injury, and inflammation and a trend toward significant improvement in target-vessel patency. Conclusions Perhaps because of reduced myocardial injury, inflammation, and activation of coagulation, patients undergoing the hybrid procedure had better perioperative outcomes and satisfaction, with excellent patency at 1 year's follow-up. These promising preliminary findings warrant further investigation of this procedure.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective Residual clot strands within the excised saphenous vein are an increasingly recognized sequela of endoscopic vein harvest. We hypothesized that endoscopic visualization facilitated by ...sealed carbon dioxide insufflation causes stagnation of blood within the saphenous vein. In the absence of prior heparin administration, this stasis provokes clot formation. Methods Forty consecutive patients having coronary artery bypass grafting underwent endoscopic vein harvest using sealed (Guidant VasoView, n = 30; Guidant Corp, Minneapolis, Minn) or open (Datascope ClearGlide, n = 10; Datascope Corp, Montvale, NJ) carbon dioxide insufflation followed by ex vivo assessment of intraluminal saphenous vein clot via optical coherence tomography. In the sealed carbon dioxide insufflation groups, clot formation was compared with (preheparinized, n = 20) and without (control, n = 10) heparin administration before endoscopic vein harvest, either at a fixed dose or titrated to an activated clotting time greater than 300 seconds. Risk factors for clot formation were assessed. Results Residual saphenous vein clot was a universal finding in control veins (sealed carbon dioxide insufflation endoscopic vein harvest without preheparinization). At either dose used, heparin given before endoscopic vein harvest significantly decreased saphenous vein clot burden. A similar reduction in clot was observed when using open carbon dioxide insufflation endoscopic vein harvest without preheparinization. Intraoperative blood loss and blood product requirements were similar in all groups. Patient age and preoperative maximum amplitude of the thrombelastography tracing showed a linear correlation with saphenous vein clot volume. Conclusion By enabling the quantification of this issue as never before possible, optical coherence tomography screening revealed that intraluminal saphenous vein clot is frequently found after endoscopic vein harvest. Systemic heparinization before harvest or an open carbon dioxide endoscopic vein harvest system are benign changes in practice that can significantly lessen this complication.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective Vasospasm is the primary obstacle to widespread adoption of the radial artery as a conduit in coronary artery bypass grafting. We used optical coherence tomography, a catheter-based ...intravascular imaging modality, to measure the degree of radial artery spasm induced by means of harvest with electrocautery or a harmonic scalpel in patients undergoing coronary artery bypass grafting. Methods Radial arteries were harvested from 44 consecutive patients with a harmonic scalpel (n = 15) or electrocautery (n = 29). Vessels were imaged before harvesting and after removal from the arm, with saphenous vein tracts serving as internal controls. Optical coherence tomographic findings for the degree of harvesting-induced injury were validated against histologic measures. Results Optical coherence tomographic measures of endovascular dimensions and injury correlated strongly with histologic findings. Mean luminal volume, a measure of vasospasm, decreased significantly less after harvesting with a harmonic scalpel (9% ± 7%) than with electrocautery (35% ± 6%, P = .015). Completely intact intima was present in 11 (73%) of 15 radial arteries harvested with a harmonic scalpel (73%) compared with 9 of 29 arteries harvested by means of electrocautery (31%, P = .011). Intraoperative flow measurements and patency rates at 5 days postoperatively were not significantly different among groups. Conclusions Optical coherence tomography provides a level of speed and accuracy for quantifying endothelial injury and vasospasm that has not been described for any other modality, suggesting potential as an intraoperative quality assurance tool. Our optical coherence tomographic findings suggest that the harmonic scalpel induces less spasm and intimal injury compared with electrocautery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Concerns about intimal disruption and spasm have limited enthusiasm for endoscopic radial artery harvest (ERAH), although the risk of these problems after this procedure remains uncertain. ...Radial artery conduits were screened intraoperatively before and after ERAH vs open harvest using catheter-based high-resolution optical coherence tomography (OCT) imaging. Methods Twenty-four cadavers and 60 coronary artery bypass graft (CABG) patients scheduled to receive a RA graft underwent OCT imaging before (in situ) and after (ex vivo) open harvest or ERAH. Spasm was quantified by the percentage change in luminal volume between images. Intimal disruption was classified as minor or severe depending on whether the defect was confined to branch ostia or involved the luminal surface. Histology was used to confirm OCT findings. Results Luminal volume significantly declined after harvest in all RAs from CABG patients, but there was no difference between groups: −43% ± 29% vs −35% ± 38% change after ERAH (n = 21) vs open harvest (n = 39; p = 0.342). Significantly more intimal injury was noted after ERAH vs open harvest (34/41 vs 9/43, intimal tears/total evaluated RAs, p < 0.0001). Most intimal injury was minor: only 2 tears involved the luminal surface of the RA (both after ERAH). Serial imaging in cadavers revealed that 86% of ostial tears occur in ERAH during the initial blunt dissection step using the endoscope. Conclusions Although branch injury is a pitfall of ERAH, OCT imaging documented that the quality of RA procured is acceptable and comparable with open harvest. Catheter-based OCT provides an important quality assurance tool for RA harvest.
Abstract Objective The study objective was to investigate the impact of matching donor quality to recipient severity on survival after lung transplant. Methods By using the Organ Procurement and ...Transplantation Network/United Network for Organ Sharing dataset, we analyzed lung transplant recipients from May 4, 2005, to December 31, 2012. By using adjusted Cox regressions, we identified extended criteria donors as those who had 1 or more of the following: age 65 years or more, smoking history of 20 pack-years or more, diabetes mellitus, or African-American race. All other donors were considered standard donors. Recipients were categorized by lung allocation score: lung allocation score less than 70 and lung allocation score 70 or greater. Our primary outcome was 1-year survival after lung transplantation. Results Of the 10,995 lung recipients, 3792 (34%) received extended criteria donor organs. Extended criteria donors were associated with an increased hazard of death (hazard ratio HR, 1.41; 95% confidence interval CI, 1.26-1.56; P < .001). One-year survival was 87% and 82% ( P < .001) for recipients with a lung allocation score less than 70 and 80% and 72% ( P = .017) for recipients with a lung allocation score 70 or greater who received standard donor and extended criteria donor organs, respectively. In Cox regression models, the hazard of death was increased for recipients with a lung allocation score less than 70 + extended criteria donor (HR, 1.42; 95% CI, 1.27-1.60; P < .001), recipients with a lung allocation score 70 or greater + standard donor (HR, 1.37; 95% CI, 1.10-1.71; P = .005), and was the highest for recipients with a lung allocation score 70 or greater + extended criteria donor (HR, 1.81; 95% CI, 1.40-2.33; P < .001) compared with recipients with a lung allocation score less than 70 + standard donor. Conclusions Extended criteria donors are associated with reduced 1-year survival, and recipients with a lung allocation score 70 or greater who receive extended criteria donor organs have the lowest survival.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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