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Biomedical subjects

G D'Ancona

Publications and source records attributed to G D'Ancona.

At least 19 recordsLinked to original sources
PubMed2001

Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach.

Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.

Humans↗
PubMed2001

Robotically assisted video-enhanced-endoscopic coronary artery bypass graft surgery.

Since 1988, through fierce industry-driven competition and patients' preference for minimally invasive procedures, widely diffused through the media, laparoscopic cholecystectomy was universally adopted and rapidly became the "gold standard" for symptomatic cholelithiasis. Robotically assisted video enhanced-endoscopic coronary artery bypass surgery (RAVE-CABG) will most likely follow suit with its similar developmental processes for symptomatic coronary artery disease. Since 1998, there are currently two surgical robotic systems that have been used in a clinical setting for endoscopic coronary artery bypass (ECABG): the da Vinci and the ZEUS system. Although each has separate learning curves to overcome, as with any new technology, both offer the promise to contribute in the interests of reduced hospital days, earlier return to normal activity, less pain, better cosmesis, and the rethinking of surgical dogma such as wide exposure.

Coronary Artery Bypass↗
PubMed2001

Myocardial revascularization on the beating heart after recent onset of acute myocardial infarction.

OBJECTIVE: Coronary artery bypass grafting (CABG) after the recent onset of acute myocardial infarction (AMI) is associated with high morbidity and mortality. Myocardial revascularization without cardiopulmonary bypass (CPB) has been proposed as an alternative technique to treat these patients in an attempt to decrease the operative risks. METHODS: From January 1995 to June 1999, 518 patients underwent CABG after the recent onset of AMI (1-20 days): 421 patients were revascularized on-CPB and 97 patients off-CPB. Preoperative risk factors (redo operations, congestive heart failure, stroke, extensive calcification of the aorta, and dialysis) were significantly higher in the off-CPB group (p-value < 0.05). Preoperative use of intra-aortic balloon pump (IABP) (off-CPB 5.2% versus on-CPB 2.4%, p-value = NS) and emergent operations (off-CPB 5.2% versus on-CPB 2.6%, p-value = NS) were similar in both groups. Mean number of grafts per patient was 3.46 in the on-CPB group versus 1.82 in the off-CPB group (p-value < 0.005). RESULTS: Actual mortality was 2.9% in the on-CPB group versus 6.2% in the off-CPB group (p-value = NS). Morbidity was comparable in the two groups. Multivariate analysis showed that advanced age, preoperative hemodynamic instability, and left ventricular hypertrophy were independent risk factors for death. Global ischemic time and preoperative hypertension were independently related to postoperative AMI. At univariate and multivariate analysis, CPB was not related to mortality or major postoperative complications. CONCLUSION: Multivariate analysis demonstrates that CABG can be performed safely with or without CPB in patients with recent AMI. CPB is not independently related to mortality or major adverse outcomes.

Aged↗
PubMed2001

Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?

BACKGROUND: The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques. METHODS: The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups. RESULTS: Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients. CONCLUSIONS: Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a threefold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.

Adult↗
PubMed2001

Reoperative coronary artery bypass grafting with and without cardiopulmonary bypass: determinants of perioperative morbidity and mortality.

BACKGROUND: This retrospective study evaluates perioperative results of reoperative coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass (CPB). METHODS: From January 1995 to March 1999 reoperative CABG was performed on 581 patients: 307 (52.84%) patients were operated upon on-CPB and 274 (47.16%) off-CPB. Median sternotomy was used in all patients on-CPB. Median sternotomy or alternative surgical approaches were used in the off-CPB group. Data was retrospectively reviewed. To identify the variables independently related to perioperative mortality and adverse outcome, multivariate analysis was performed in the overall population of 581 patients. RESULTS: Preoperative risk factors were comparable in the two groups. Critical lesions of the right and left circumflex coronary artery were more common in the on-CPB group (p < 0.005). A total of 2.7 grafts/patient was performed in the on-CPB group versus 1.3 grafts/patient in the off-CPB group (p = NS). Freedom from postoperative complications was higher in the off-CPB group (72% versus 90.9%, p < 0.005). Perioperative stroke and respiratory failure rates were more common in the on-CPB group (3.9% versus 0.7% and 5.9% versus 2.2% respectively, p < 0.005). Actual mortality was 5.9% in the on-CPB group and 3.6% in the off-CPB group (p = NS). Risk adjusted mortality was 2.2% and 1.3% in the on-CPB and off-CPB groups respectively. Although CPB was found to be independently related to adverse outcome (odds ratio (OR) = 2.89, p-value < 0.005), no correlation was found between mortality and CPB. CONCLUSIONS: Avoidance of CPB independently reduces adverse outcomes in reoperative CABG without affecting mortality rate.

Adult↗
PubMed2001

Coronary artery exposure in off-pump cabg: a word of caution.

Coronary exposure and stabilization have focal importance in off-pump coronary surgery. Off-pump complete myocardial revascularization can be performed safely in the majority of the patients whenever strict surgical protocols are followed. Although new devices may be used to facilitate the performance of this demanding operation, technical pitfalls should be recognized to ensure the success of the procedure. We herein report our timely experience with the Xpose device (Guidant Corp., Cupertino, CA).

Aged↗
PubMed2001

OPCAB therapy survey: off-pump clopidogrel, aspirin or both therapy survey.

BACKGROUND: Standards for heparinization during off-pump coronary artery bypass (OPCAB) are lacking. Similarly, there are no established standards for antiplatelet therapy before or after OPCAB. The aim of this study was to determine current practices and standards for both antiplatelet and heparin therapy in OPCAB. METHODS: A postal, multiple-choice survey questionnaire was sent to 800 randomly chosen cardiothoracic surgeons in the United States and Canada. Responses were tabulated and analyzed. RESULTS: The overall response rate was 38% (304 surgeons). The respondents performed CABG in centers with an overall volume between 240 and 1,250 procedures per year (average 380 procedures per year). OPCAB procedures within the same institutions ranged from 20 and 375 cases per year. Sixteen percent (48) of the respondents routinely administer antiplatelet therapy preoperatively; of these, 18% (9) use clopidogrel (Plavix) and 65% (31) aspirin. Eighty-eight percent (267) of the respondents routinely administer antiplatelet therapy after OPCAB. Of these, 24% (65) use clopidogrel and 74% (197) aspirin. Anticoagulation protocols during OPCAB were more variable with 28% (85) administering full dose of heparin, 54% (164) administering half dose heparin, and 13% (40) administering 1/3 dose of heparin during construction of coronary anastomoses. Although 10% (30) maintain an activated clotting time (ACT) above 400 seconds, 70% (213) are content with an ACT above 300 seconds and less than 400 seconds, and 20% (61) responded as "other". The average blood shed postoperatively was 600 ml (range 300 ml and 1 liter). Forty percent (122) administer protamine at half dose, and 60% (182) administer a full dose. CONCLUSION: Although the vast majority of surgeons use antiplatelet therapy postoperatively, a minority administer preoperative antiplatelet agents for OPCAB. The majority of surgeons use a half dose of heparin during OPCAB with ACT maintained above 300 seconds (> 80%). Prospective studies are necessary to determine the short and intermediate effects of antiplatelet therapy and heparinization doses in OPCAB surgery.

Anticoagulants↗
PubMed2000

The innominate artery as an inflow site in coronary reoperations without cardiopulmonary bypass.

The innominate artery was used as an inflow site in 20 patients undergoing redo coronary operations without cardiopulmonary bypass. This technique was adopted when extensive adhesions and old patent grafts were present, to avoid dissection of the ascending aorta and eliminate the risk of graft injury or embolization. This strategy considerably facilitated construction of proximal anastomoses and was associated with favorable perioperative outcomes.

Brachiocephalic Trunk↗
PubMed2000

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass.

BACKGROUND: Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians. METHODS: Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared. RESULTS: The groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant). CONCLUSIONS: This investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.

Age Factors↗
PubMed2000

Reoperative "off-pump" circumflex revascularization via left thoracotomy: how to prevent graft kinking.

Reoperative circumflex revascularization can be performed through a left thoracotomy approach, with or without cardiopulmonary bypass. In such cases, establishing the appropriate length of coronary grafts connecting the descending thoracic aorta to one of the marginal branches of the circumflex coronary artery may be problematic. In fact, if these grafts are too long they may kink, whereas if left too short they may be injured by respiratory excursions of the left lower lobe of the lung. In this report we describe a technique that can prevent these potential complications.

Humans↗
PubMed2000

Survey of resident training in beating heart operations.

BACKGROUND: "Off-pump" coronary artery operations are done with increasing frequency in the treatment of coronary artery disease. As a result, residents in thoracic surgery have been confronted with the necessity of gaining experience in this innovative approach to coronary surgery. The aim of this study was to assess the importance of training in minimally invasive coronary revascularization as it was perceived by thoracic surgery residents. METHODS: A postal, multiple-choice survey questionnaire was sent to all cardiothoracic surgery residents (n = 327) of accredited training programs in the United States. Responses were tabulated and analyzed. RESULTS: The overall response rate was 68% (222 of 327 residents). The attending staff was very interested (37%), or had some interest (63%), in beating heart coronary revascularization. Ninety-eight percent of the programs had at least one surgeon performing off-pump procedures. Although 88% of the responding residents showed some interest in off-pump coronary operations, only 22% of them had performed more than 20 off-pump cases, and even less (12%) had performed more than 20 cases of off-pump complete revascularization, or off-pump circumflex revascularization (4%). Sixteen percent of them had no clinical experience with these techniques. Regarding career intentions, 88% of the residents indicated that off-pump coronary operations were expected to be part of the practice, and 58% of them were interested in pursuing additional training in less invasive heart procedures. CONCLUSIONS: The results of this survey suggest that training in off-pump coronary revascularization is variable across training programs, and that the majority of residents may not reach proficiency in coronary procedures on the beating heart during their residency. This may adversely affect their future expectations, as 88% of them would like to practice off-pump coronary surgery once the training is completed.

Cardiopulmonary Bypass↗
PubMed2000

Exposure and mechanical stabilization in off-pump coronary artery bypass grafting via sternotomy.

Although off-pump coronary artery bypass grafting (CABG) is gaining popularity, obtaining exposure and stabilization of coronary arteries located on the lateral and inferior wall of the heart may be problematic. The aim of this study is to describe strategies and techniques of coronary exposure and mechanical stabilization that may be used to achieve total myocardial revascularization of the beating heart.

Coronary Artery Bypass↗