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Biomedical subjects

Todd M Dewey

Publications and source records attributed to Todd M Dewey.

At least 19 recordsLinked to original sources
PubMed2007

Ventricular epicardial lead placement for resynchronization by determination of paced depolarization intervals: technique and rationale.

BACKGROUND: Cardiac resynchronization therapy has been shown to be an effective treatment to improve functional status and prolong survival among patients with advanced congestive heart failure. However, as many as 30% of patients do not respond. Nonresponse may be due to suboptimal left ventricular lead placement. Studies have indicated that leads placed in the midlateral left ventricle (LV) wall usually result in improved dP/dT and increased pulse pressure, compared with other locations. When the surgeon is placing the leads thoracoscopically, however, in a chest with multiple adhesions, anatomic landmarks can be obscured. It is desirable to have an objective physiologic method to determine optimal lead placement. The optimal LV pacing site may be best determined by locating the site with the latest depolarization. METHODS: A pacing lead attached to a pulse analyzer was introduced through a thoracoscopic port and used as a mapping electrode to electrically map exposed areas of the left ventricle. The right ventricular pacing lead was also attached to the pulse analyzer and the interval between the right ventricular pulse and the LV depolarization (paced depolarization interval) was measured in 19 patients undergoing thoracoscopic LV lead placement. A site with a paced depolarization interval less than 110 ms was not accepted. RESULTS: Electrical mapping was possible in 19 of 29 consecutive patients in whom it was attempted. The most frequent reason for not mapping was the presence of extensive scarring. In 7 of 19 patients (36.8%) mapped, the site that would have been chosen by anatomic landmarks was not the site with the longest paced depolarization interval, and thus the lead placement was altered. CONCLUSIONS: The site with the longest paced depolarization interval is only selected 63.2% of the time when utilizing anatomic landmarks for placement. Nonresponse may be due to suboptimal LV lead placement. Measurement of paced depolarization intervals provides a physiologic method of determining optimal LV lead placement.

Cardiac Pacing, Artificial↗
PubMed2006

Does coronary artery bypass graft surgery improve survival among patients with end-stage renal disease?

BACKGROUND: Cardiovascular disease remains the most frequent cause of death for patients with end-stage renal disease. To determine the long-term benefit of surgical revascularization in this high-risk population, we studied our patients with ESRD having coronary artery bypass graft surgery (CABG), comparing the results of off-pump to on-pump revascularization. As a baseline reference group, we used dialysis patients with a diagnosis of coronary artery disease who did not have surgical revascularization or percutaneous coronary interventions. The control group data set was obtained from the United States Renal Data System. METHODS: From January 1995 through July 2003, 158 patients with end-stage renal disease who were on hemodialysis (excluding those in cardiogenic shock, needing resuscitation, and with emergent or salvage status) underwent CABG. Fifty-nine patients (37.3%) had off-pump revascularization, and 99 patients (62.7%) had bypass grafting utilizing extracorporeal circulation. Preoperative risk factors and operative results were analyzed, and longitudinal survival data obtained. RESULTS: The mean follow-up time was 39.1 months (median, 33.1) for the on-pump patients and 18.3 months (median, 14.7) for off-pump. The total number of anastomoses per off-pump patient was 2.4 +/- 1.0, and with cardiopulmonary bypass (CPB), it was 3.3 +/- 0.9 (p < 0.001). Patients revascularized off-pump had an operative mortality rate of 1.7%, whereas patients grafted using CPB had an operative mortality of 17.2% (p = 0.003). The predicted risk of mortality for the off-pump group (9.3% +/- 7.4%) was not statistically different from the on-pump cohort (9.1% +/- 7.7%, p = not significant). Logistic regression analysis indicates that CPB use was an independent risk factor for early death (p = 0.01, odds ratio = 13.6, 95% confidence interval: 1.7 to 110). Long-term follow-up demonstrated that the patients revascularized using CPB had improved survival compared with the off-pump patients and the control population. CONCLUSIONS: Off-pump CABG improves early mortality rate when compared with conventional revascularization. Despite a greater operative mortality, however, long-term survival is improved in the patients revascularized with CPB as compared with the off-pump cohort, suggesting possible advantages from a more complete revascularization in this population.

Aged↗
PubMed2006

One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis: outcomes and consequences.

BACKGROUND: Thoracic sympathectomy is recognized as an effective treatment for patients with severe hyperhidrosis. While good early results have been documented, continuing efficacy and patient satisfaction has not been well-defined. We reviewed our results in patients who were at least one year out from surgery. METHODS: All procedures were performed thoracoscopically using bilateral 3 mm ports and excision of a segment of the sympathetic chain by electrocautery. The level of sympathectomy depended upon clinical symptoms: T2 for face/scalp, T3 for palmar hyperhidrosis, and T4 for axillary hyperhidrosis, or a combination of levels for multiarea sweating. All patients were followed-up at least 1 year postprocedure by mail questionnaire and/or telephone. RESULTS: Two hundred twenty-two patients had undergone thoracoscopic sympathectomy for essential hyperhidrosis between Jan 1, 2002 and Nov 30, 2003, with 170 patients having at least one-year follow-up. The patients' preoperative assessment of the severity of sweating in the affected areas was compared with their one-year evaluation in order to determine the durability of the procedure. All affected areas continued to show significant improvement in sweating as compared with preoperative symptoms. Compensatory sweating was reported in 85% of our patients at one-year follow-up. Patients with a T2 lesion were significantly more likely to have severe compensatory sweating than those with other levels; 48.8% vs 16.1% (p < 0.001). Patients with levels other than T2 reported high degrees of satisfaction unrelated to their postoperative compensatory symptoms. CONCLUSIONS: Patient satisfaction and perceived effectiveness with sympathectomy for palmar or axillary hyperhidrosis remain high even one year after the procedure. Inclusion of the T2 lesion results in significantly more severe compensatory sweating and reduced satisfaction than other levels.

Adolescent↗
PubMed2006

Reduced atrial fibrillation in patients immediately extubated after off-pump coronary artery bypass grafting.

BACKGROUND: We analyzed data from patients undergoing off-pump isolated coronary artery bypass grafting surgery (OPCABG) to determine if immediate extubation in the operating room affected the incidence of postoperative atrial fibrillation. METHODS: The study group comprised 2,376 consecutive OPCABG patients operated on between January 1, 2000, and December 31, 2004, by 22 surgeons at 18 hospitals. The data were subjected to univariate, multivariate analysis of variance, and logistic analysis. Logistic regression of matched groups was used to eliminate the effect of some confounding variables. RESULTS: Patients immediately extubated after surgery had a reduced incidence of atrial fibrillation (10.6% versus 18.5%; p < 0.001), shorter length of stay (4.8 +/- 3.5 versus 6.3 +/- 5.2 days; p < 0.001), and also reduced mortality (1.1% versus 2.4%; p = 0.04). Logistic analysis identified as significant factors for postoperative atrial fibrillation, postoperative ventilator usage (p < 0.001; odds ratio [OR] = 1.63; 95% confidence interval [CI]: 1.24 to 2.14), male sex (p = 0.002; OR = 1.51; 95% CI: 1.17 to 1.96), previous CABG (p = 0.005; OR = 0.43; 95% CI: 0.24 to 0.78). Congestive heart failure may also be a contributing factor. In patient groups matched for their risk of mortality, postoperative ventilator use (p < 0.001; OR = 1.80; 95% CI: 1.31 to 2.47), increasing age, and male sex were all statistically significant risk factors. When patient groups were matched on a combination of factors including preoperative beta-blocker usage, pulmonary disease, and smoking, postoperative ventilator use (p = 0.005; OR = 1.66; 95% CI: 1.16 to 2.38), along with increasing age, male sex, and previous CABG (reduced odds of atrial fibrillation developing) were statistically significant. CONCLUSIONS: Immediate extubation after OPCABG appears to reduce the incidence of postoperative atrial fibrillation independent of comorbidities.

Adrenergic beta-Antagonists↗
PubMed2006

Transapical aortic valve implantation: an animal feasibility study.

BACKGROUND: Percutaneous aortic valve implantation has recently been performed in nonsurgical patients with severe aortic stenosis. Retrograde valve delivery has been problematic because of the size of the delivery system and concomitant peripheral vascular disease. We investigated a minimally invasive approach through the left ventricular apex for antegrade placement of a device-deliverable valve. METHODS: Transapical aortic valve implantation was performed using a 23-mm equine valve mounted on a stainless steel stent in 24 swine (weight range, 35 to 45 kg). A limited or full sternotomy approach was used to access the apex of the heart. The crimped valve was introduced through a sheath in the left ventricular apex. Fluoroscopy and echocardiography were used for guidance. Deployments were performed on the beating heart either with ventricular unloading using femoral extracorporeal circulation or rapid ventricular pacing. RESULTS: All valves were successfully delivered at the selected target site with acceptable visualization of the noncalcified aortic annulus. Valve migration occurred during eight deployments (two distal and six retrograde) secondary to persistent cardiac output, unfavorable annular anatomy, and dislodgement by the delivery catheter. Exact positioning of the nonmigrated valves at the aortic annulus was examined by necropsy of all animals at the end of the procedures. Paravalvular leak was noted in 14 of 18 (77.8%) valves remaining in situ. CONCLUSIONS: The transapical approach was used for the successful antegrade placement of a stented valve, obviating the technical problems associated with a large delivery system transiting the peripheral vascular system. Stent design contributing to paravalvular leak remains problematic.

Animals↗
PubMed2006

The occurrence of postoperative pulmonary homograft stenosis in adult patients undergoing the Ross procedure.

BACKGROUND AND AIM OF THE STUDY: The Ross procedure employs an autologous pulmonary valve to replace the aortic valve, but requires pulmonary homograft replacement. Concerns regarding long-term homograft function may limit the adoption of this technique. Herein, the incidence of, and factors leading to, stenosis of the homograft were examined. METHODS: Data were collected from 131 patients (32 females, 99 males) who underwent a Ross procedure between July 1994 and December 2003. Complete follow up data were collected from 113 of 125 (90.4%) living patients. Donor valve information, including storage time, was supplied by the graft manufacturers. Data were analyzed using chi-square tests, t-test and logistic regression. RESULTS: The mean patient follow up was 703 +/- 574 days (median 599 days; range: 2 to 2,408 days). Echocardiographic stenosis had occurred in 14 patients (12.4%). Four patients (3.2%) required homograft replacement, and two required balloon valvuloplasty. There was no significant difference in graft vendor, recipient, donor age or blood type match between stenotic and non-stenotic recipients. Donor valve size was appropriate for the recipients, and greater than predicted by recipient body surface area (BSA). Donor valves that developed stenosis had a shorter storage time after processing (160 +/- 100 versus 249 +/- 223 days; p = 0.03). Male donor valves became stenotic in 9.9% (7/71) of male recipients, but in none of 20 females. Female donor valves became stenotic in 27.3% (3/11) of male recipients, and in 28.6% (2/7) females. Logistic regression showed donor gender to be a significant predictor for stenosis (p = 0.007; odds ratio 14.1 for female/male donors; 95% CI 2.1-96.4). CONCLUSION: Donor valves which developed stenosis had a shorter mean cryopreservation time than those that did not develop stenosis. In addition, female donor homografts appeared to develop stenosis at a greater rate, independent of patient age, graft size to BSA match, and blood type.

Adolescent↗
PubMed2005

Improvement of renal dysfunction by conversion from calcineurin inhibitors to sirolimus after heart transplantation.

BACKGROUND: Chronic renal dysfunction is a common occurrence after heart transplantation in patients treated with calcineurin inhibitors (CIs). We evaluated the renal-sparing effects of converting stable heart transplant patients with renal dysfunction from a CI to sirolimus. METHODS: Beginning in 2000, heart transplant patients with renal dysfunction were converted from a CI to sirolimus. CI was abruptly discontinued and sirolimus added at 5 mg twice a day for 2 days and then 2 mg daily. The treatment goal was a 24-hour level of 6 to 12 ng/ml. All patients were also managed with mycophenolate mofetil (MMF) at 1,000 mg twice daily. RESULTS: Eighty from a total of 235 cardiac transplant patients were converted to sirolimus. The average time post-transplant for conversion was 4.78 years (range 3 days to 16 years). The average age at transplant was 55.43 years (range 15 to 70). At a mean of 304 days post-conversion, the mean serum creatinine (sCr) decreased from 2.04 +/- 0.57 mg/dl pre-conversion to 1.64 +/- 0.48 mg/dl (p < 0.001). In patients whose sCr was <2.5 mg/dl before conversion, the mean SCr level decreased from 1.81 +/- 0.39 to 1.62 +/- 0.5 mg/dl post-conversion (p = 0.01), with no patient developing end-stage renal disease (ESRD). Four patients with sCr > or =2.5 developed ESRD requiring dialysis despite conversion. In the remaining 15 patients with sCr > or =2.5 mg/dl, the sCr decreased from 2.85 +/- 0.29 to 1.73 +/- 0.43 mg/dl (p = 0.001). CONCLUSIONS: Conversion to sirolimus from CI is safe and has a renal-sparing effect in the management of heart transplant patients with chronic renal dysfunction. Based on these results, sirolimus has a role as a first-line immunosuppressive agent in heart transplant patients with renal dysfunction.

Adolescent↗
PubMed2005

Does reporting of coronary artery bypass grafting from administrative databases accurately reflect actual clinical outcomes?

OBJECTIVES: Quality assessment of coronary artery bypass grafting has traditionally been performed with data from clinical databases. Administrative databases that rely primarily on information collected for billing purposes increasingly have been used as tools for public reporting of outcomes quality. The correlation of administrative data with clinical data for clinical quality assessment has not been confirmed. METHODS: With data from a clinical database, we analyzed the outcomes of all patients who underwent coronary artery bypass grafting surgery in 1 hospital between 1999 and 2001. This information was collected before, during, and after the surgery and hospitalization by designated clinical individuals involved with the patient's care and then entered into an audited clinical database (The Society of Thoracic Surgeons National Cardiac Database). These data were then compared with administrative data collected on the same cohort of patients for the number of procedures performed and mortality rate as reported by the federal government (Medical Provider Analysis and Review), state government (Texas Health Care Information Council), hospital system (HCA, Inc, Casemix Database), and an internet Web site (healthgrades.com). Data were analyzed on the basis of the population reported, definitions used, risk assessment algorithms, and case volumes. RESULTS: By using the audited The Society of Thoracic Surgeons database as the standard and aggregating the reporting of case volumes by the inclusion criteria of various sources of administrative data, we found variances in the reported procedure volumes and mortality. Case volumes were overreported by as much as 21% in all patients and underreported by up to 16% or more in Medicare patients. Mortality in administrative data exceeded that reported in clinical data by 21%. Reasons for variances included time period reported (calendar vs fiscal year), population reported (all patients, Medicare patients, Medicare patients aged >/= 65 years), date used for the patient record captured (date of surgery, discharge), and the definition of mortality. Different proprietary risk-adjusting algorithms used magnified variances with risk-adjusted mortality exceeding the Society of Thoracic Surgeons data by as much as 61%. CONCLUSIONS: Substantial variability of reported outcomes is seen in administrative data sets compared with an audited clinical database in the end points of the number of procedures performed and mortality. This variability makes it challenging for the nonclinician unfamiliar with outcomes analysis to make an informed decision.

Aged↗
PubMed2005

Mitral valve surgery using the classical 'heartport' technique.

BACKGROUND AND AIM OF THE STUDY: Mitral surgery in selected patients using femoral cannulation, percutaneous retrograde cardioplegia and endoballoon aortic occlusion with a 4-5 cm thoracotomy is felt to carry a higher operative risk than sternotomy with conventional cannulation. Herein, the authors compared their experience of the first 117 'Heartport' (HP) patients with a computer-matched group of sternotomy approach surgical patients (SP) to assess operative risk and 30-day outcome. METHODS: Data were extracted from the authors' STS certified, audited database on 117 patients based on an intention to treat. Between December 1997 and December 2004, a total of 92 isolated mitral valve (MV) repair (HP-MVRpr) and 25 isolated MV replacement (HP-MVR) procedures was conducted using Heartport. The patients were matched 1:1 (by age +/-7 years, cerebrovascular disease, inotrope use, and ejection fraction +/- 5%) to a control SP group. Operative and 30-day outcomes were measured. RESULTS: No parameter showed any significant difference in 30-day outcome between the HP and SP groups, except for an increase in cross-clamp and perfusion times. Two patients in the HP-MVRpr group required conversion to sternotomy for repair of coronary sinus perforation, and one patient was repaired without conversion. Surgery in one HP-MVRpr patient was aborted due to limited aortic dissection, but successful repair was carried out later with a conventional approach. No patient required conversion to sternotomy for improved exposure of the operative site. CONCLUSION: Despite a longer cross-clamp time, 'classical' HP MV surgery can be performed with no increased risk compared to conventional MV surgery. Catheter and endoballoon complications were rare even in the early experience, and conversion to sternotomy was unusual and safely performed with this approach.

Adult↗
PubMed2004

Experience with various surgical options for the treatment of atrial fibrillation.

BACKGROUND: New alternatives exist using various energy sources and lesion lines for the surgical treatment of atrial fibrillation (AF). The efficacy of these options compared to the cut-and-sew maze III procedure is unknown. METHODS: From August 1996 to August 2003, 79 patients have undergone a procedure for AF, with 70 patients currently more than 3 months postsurgery. The patients (58 continuous, 12 paroxysmal) underwent a surgical procedure for AF, lone AF (12) and with concomitant procedures (58). Techniques included cut and sew (23), bipolar radiofrequency (RF) (28) and unipolar-RF (10), and cryothermy (9). Lesions included maze III (46), pulmonary vein isolation (16), and pulmonary vein isolation plus mitral annular connecting line only (8). RESULTS: Follow-up was complete in 58 (83%) of 70 patients at a mean time of 595 +/- 750 days (range, 24-2530 days). The operative mortality was 0% in lone AF patients and 7.1% (5/70) in patients undergoing concomitant procedures. Need for perioperative pacemaker was 22.9%. Overall, normal sinus rhythm (NSR) was restored in 82.7% of patients, with success in 83.3% (10/12) lone procedures and 82.6% (38/46) concomitant procedures ( P = NS); the rate of continuous AF was 85.1% (40/47) and SR with paroxysmal fibrillation was 72.7% (8/11) ( P = NS). Traditional maze was successful in 80.6% (29/36) patients, pulmonary vein isolation was successful 93.3% (14/15), and left-sided maze in 71.4% (5/7) ( P = NS). Cut and sew procedures were successful in 88.2% (15/17), RF-bipolar in 84.0% (21/25), RFunipolar in 77.8% (7/9), and cryothermy in 71.4% (5/7) ( P = NS). Energy source, lesion set, AF duration, and lone/concomitant procedure were the factors subjected to logistic regression analysis. No factors were predictive of achieving postoperative NSR. CONCLUSIONS: Our early experience with newer surgical techniques employing different energy sources and fewer incision lines suggests that the success rate may approach the results obtained with traditional cut-and-sew Cox-maze III procedures.

Atrial Fibrillation↗
PubMed2004

Avoidance of Cardiopulmonary Bypass Improves Early Survival in Multivessel Coronary Artery Bypass Patients with Poor Ventricular Function.

Abstract Background: Patients with diminished ventricular function represent an increasing percentage of candidates for coronary artery bypass grafting (CABG). We have reviewed our recent experience in CABG in patients with ejection fractions (EF) </=30% to identify factors leading to improved outcomes in this high-risk group. Methods: Between January 1997 and September 2002, 990 patients with EF </=30% underwent CABG. Univariate and logistic regression analysis was used to analyze data from 204 patients who underwent revascularization off-pump and 713 patients who underwent grafting with cardiopulmonary bypass (CPB) for differences in mortality, morbidity, and length of stay (LOS). Results: Compared with the on-pump patient cohort, patients with depressed ventricular function who underwent revascularization without the use of CPB had a lower operative mortality rate that trended toward significance (2.9% versus 6.3%; P =.06) and a significantly lower risk-adjusted mortality rate (1.47% versus 4.13%; P <.001), despite a higher predicted risk (5.4% +/- 5.5% versus 4.3% +/- 3.7%; P =.01). Additionally, patients who underwent off-pump bypass grafting had a significantly lower incidence of reoperation for bleeding (1.0% versus 4.6%; P =.02), lower blood product use (39.6% versus 66.6%; P <.001), decreased postoperative ventilation times (11.3 +/- 37.4 hours versus 46.1 +/- 156.1 hours; P <.001), and fewer days in the intensive care unit (2.6 +/- 3.8 days versus 4.2 +/- 6.5 days; P <.001). Logistic regression analysis showed that CPB use ( P =.048; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0-5.8) and previous CABG ( P =.015; OR, 2.6; 95% CI, 1.2-5.7) were independent risk factors for mortality. A trend toward a shorter LOS (7.6 +/- 7.9 days versus 8.9 +/- 9.6 days; P =.06) was also seen in the off-pump patients. Conclusion: Avoidance of CPB in patients with reduced ventricular function undergoing multivessel bypass improves early survival rates and decreases the incidence of reoperation for bleeding, blood product use, and postoperative ventilatory times.

Journal Article↗
PubMed2004

First-year outcomes of beating heart coronary artery bypass grafting using proximal mechanical connectors.

BACKGROUND: To determine the extended results of mechanical connectors we compared the 1-year outcomes of patients having beating heart coronary artery bypass surgery with at least one sutured or mechanically connected proximal vein graft anastomosis. METHODS: From May 2001 to December 2001, 166 patients were identified as having undergone off-pump bypass grafting utilizing at least one St. Jude symmetry aortic connector (St Jude Medical Anastomotic Technology Group, St. Paul, MN). Follow-up for major adverse cardiac events (MACEs), which is defined as cardiac mortality, myocardial infarction, or revascularization of a previous target vessel, was obtained on 162 patients (97.6%). A control group of 159 patients was identified from a cohort of patients having beating heart surgery with one or more sutured proximal vein graft anastomosis in the preceding year. The MACE follow-ups were obtained in 136 patients (85.6%) by direct telephone contact. RESULTS: Patients with connectors showed an accelerated number of MACEs beginning approximately 180 days from the time of surgery and stabilizing at approximately 300 days. Logistic regression analysis identified the presence of diabetes as a significant preoperative risk factor predisposing patients to earlier onset of MACEs (p = 0.03) with an odds ratio of 2.9 (95% confidence interval, 1.1 to 7.6). Insulin dependent diabetics showed no differences between connector and control patients in the frequency or timing of MACEs. Connector patients using oral hypoglycemic agents demonstrated a significant deviation (p = 0.01) from a similar control population in the prevalence and timing of MACEs. CONCLUSIONS: Connector patients showed an increased incidence of early MACEs. These events were characterized by an increased requirement for early target vessel revascularization and were predominantly in noninsulin-dependent diabetics.

Aged↗
PubMed2003

Safety and efficacy of minimally invasive atrial septal defect closure.

BACKGROUND: Atrial septal defects (ASDs) have been surgically closed with low mortality utilizing the conventional sternotomy approach (CSA). The technical ease of ASD closure has triggered interest in minimally invasive closure (MIC) to obviate the morbidity associated with sternotomy. Our study assesses the safety and efficacy of minimally invasive ASD closure. METHODS: Preoperative, intraoperative, and postoperative data were collected on 68 patients (39 CSA, 29 MIC) who underwent ASD closure from January 1997 to August 2002. Using univariate analysis of 17 preoperative risk factors there was no statistically significant difference between the two groups. RESULTS: MIC resulted in equivalent success rates in ASD closures, with similar morbidity, no mortality, and a significant difference in postoperative length of stay (3.93 +/- 1.6 days versus 5.36 +/- 2.51 days, p = 0.006). CONCLUSIONS: In experienced hands, MIC is an excellent alternative to CSA in ASD closure.

Adult↗
PubMed2003

Initial experience with proximal anastomoses performed with a mechanical connector.

BACKGROUND: The Symmetry Bypass System Aortic Connector (St Jude Medical, Inc) is a novel device for the construction of sutureless proximal anastomoses. The connector allows attachment of saphenous vein grafts to the aorta without requiring aortic clamping. We report our initial clinical experience with this device. METHODS: In a 2-month period from May to July 2001, a total of 139 consecutive proximal anastomoses were performed in 67 patients using the connector. All procedures were performed on a beating heart without cardiopulmonary bypass or any aortic clamping. Intraoperative variables and postoperative results were prospectively collected and retrospectively analyzed. RESULTS: Of 139 consecutive proximal anastomoses 138 (99.3%) were successfully completed with the device. One anastomosis required suture revision because of misdeployment. Six anastomoses (4.3%) required an additional suture for leak. Predeployment problems included connector loading/preparation malfunction in 10 grafts (7.2%), five because of human error and five technical failure. There was no operative mortality, perioperative myocardial infarction, or stroke. Vessels bypassed included the circumflex system (n = 59), right coronary artery and branches (n = 48), diagonal branch (n = 26), and left anterior descending coronary artery (n = 6). At a mean follow-up of 7 months, survival was 94.1% and survival free of major adverse cardiac and cerebrovascular events (MACCE) was 88.1%. CONCLUSIONS: Initial clinical experience with a sutureless proximal saphenous vein graft to aorta anastomosis performed with a mechanical connector demonstrates safety, reliability, and ease of use. Surmounting a brief learning curve improves the subtleties of device loading and deployment. Further benefits will be determined in an ongoing randomized study.

Adult↗
PubMed2003

Conversion in off-pump coronary artery bypass grafting: an analysis of predictors and outcomes.

BACKGROUND: The incidence, predictive factors, and outcomes related to conversion from off-pump coronary artery bypass (OPCAB) to on-pump coronary artery bypass grafting (ONCAB) have not been well defined. We sought to determine the incidence of conversion, predictive factors, and any associated adverse consequences. METHODS: From January 2000 through June 2002, 1,644 patients underwent nonemergent OPCAB with 61 patients requiring conversion from OPCAB to ONCAB. These groups were retrospectively compared by univariate and multivariate regression analysis. The converted group was then computer matched 1:3, to a cohort of ONCAB patients to determine differences in outcomes. RESULTS: The overall conversion rate was 3.71%. Converted patients compared with a computer-matched ONCAB patients had a higher incidence of operative mortality (18.0% versus 2.7%, p < 0.001). Urgently converted patients had a higher incidence of postoperative cardiac arrest (25% versus 1.1%, p < 0.001), multisystem organ failure (10.7% versus 0.6%, p < 0.001), vascular complications (7.1% versus 1.1%, p = 0.03), and perioperative myocardial infarction (10.7% versus 1.1%, p = 0.02). Predictive factors for conversion were surgeon early in OPCAB experience (odds ratio [OR] 4.4), previous CABG (OR 2.8), and congestive heart failure (OR 2.0). The need for urgent-emergent conversion was highly predictive for operative mortality (OR 7.3) compared with elective conversion. CONCLUSIONS: Patients undergoing urgent-emergent but not elective conversion from OPCAB to ONCAB had a significantly higher risk of mortality and morbidity compared with patients whose procedure was initially ONCAB. Variables predictive of conversion included previous CABG, congestive heart failure, and surgeons early in OPCAB experience.

Cardiopulmonary Bypass↗
PubMed2003

Complications related to off-pump bypass grafting.

Surgical myocardial revascularization is a technique undergoing critical reevaluation in an attempt to reduce operative morbidity and mortality. As the age and number of comorbidities in the surgical population presenting for bypass increases, improved strategies to lessen operative risk have evolved. The use of off-pump bypass grafting to avoid the detrimental effects of extracorporeal circulation demonstrates great promise in reducing operative complications. However, with new techniques come new challenges. Avoidance of the cardiopulmonary bypass circuit has been linked to the development of a hypercoagulable state postoperatively. Complications related to the unique management of the ascending aorta and target vessels during the performance of beating heart surgery are also being reported. Moreover, despite increasing experience in a number of centers, hemodynamic collapse does occur during off-pump bypass, thereby requiring rapid institution of cardiopulmonary bypass. Continued scientific investigation and research should provide the tools to manage the unique obstacles encountered with off-pump coronary artery bypass.

Aortic Dissection↗
PubMed2002

Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients.

BACKGROUND: Coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass (CPB) is currently increasing in clinical practice. Decreased morbidity associated with off-pump (OP) CABG in selected risk groups examined in relatively small, single institution groups has been the focus of most recent studies. The purpose of this study was to determine the independent impact of CPB on early survival in all isolated multivessel CABG patients undergoing surgery in two large institutions with established experience in OPCABG techniques. METHODS: A review of two large databases employed by multiple surgeons in the hospitals of two institutions identified 8,758 multivessel CABG procedures performed from January 1998 through July 2000. In all, 8,449 procedures were included in a multivariate logistic regression analysis to determine the relative impact of CPB on mortality independent of known risk factors for mortality. Procedures were also divided into two treatment groups based on the use of CPB: 6,466 had CABG with CPB (CABG-CPB), 1,983 had CABG without CPB (OPCABG). Disparities between groups were identified by univariate analysis of 17 preoperative risk factors and treatment groups were compared by Parsonnet's risk stratification model. Finally, computer-matched groups based on propensity score for institution selection for OPCABG were combined and analyzed by a logistic regression model predicting risk for mortality. RESULTS: CABG-CPB was associated with increased mortality compared with OPCABG by univariate analysis, 3.5% versus 1.8%, despite a lower predicted risk in the CABG-CPB group. CPB was associated with increased mortality by multiple logistic regression analysis with an odds ratio of 1.79 (95% confidence interval = 1.24 to 2.67). An increased risk of mortality associated with CPB was also determined by logistic regression analysis of the combined computer-matched groups based on OPCABG-selection propensity scores with an odds ratio of 1.9 (95% confidence interval = 1.2 to 3.1). CONCLUSIONS: Elimination of CPB improves early survival in multivessel CABG patients. Rigorous attempts to statistically account for selection bias maintained a clear association between CPB and increased mortality. Larger multiinstitutional studies are needed to confirm these findings and determine the most appropriate application of OPCABG.

Aged↗