Systematic off-pump coronary artery revascularization in multivessel disease: Experience of three hundred cases

AbstractObjective: We sought to report our recent experience with off-pump coronary artery revascularization in multivessel disease. Methods: Between October 1996 and December 1998, 300 off-pump beating heart operations were performed at the Montreal Heart Institute by a single surgeon, representing 94% of all procedures undertaken during this same time frame (97% for 1998). This cohort of patients was compared with 1870 patients operated on with cardiopulmonary bypass from 1995 to 1996. Results: Mean age, sex distribution, and preoperative risk factors were comparable for the two groups. On average, 2.92 ± 0.8 and 2.84 ± 0.6 grafts per patient were completed in the beating heart and cardiopulmonary bypass groups, respectively. A majority of patients (70%) had either a triple or quadruple bypass. Coronary anastomoses were achieved with myocardial mechanical stabilization and heart “verticalization.” Ischemic time was shorter in the beating heart group (29.8 ± 0.9 vs 45 ± 0.4 minutes, P < .05). Similarly, the need for transfusion was significantly less in the beating heart group (beating heart operations, 34%; cardiopulmonary bypass, 66%; P < .005). Reduced use of postoperative intra-aortic counterpulsation, as well as a lower rise in creatine kinase MB isoenzyme, was observed in the beating heart group. Operative mortality rates (beating heart operations, 1.3%; cardiopulmonary bypass, 2%) and perioperative myocardial infarction (beating heart operations, 3.6%; cardiopulmonary bypass, 4.2%) were comparable for the two groups. Conclusion: In a majority of patients, off-pump complete coronary artery revascularization is an acceptable alternative to conventional operations, yielding good results given progressive experience, rigorous technique, and adequate coronary artery stabilization. (J Thorac Cardiovasc Surg 2000;119:221-9

Perioperative Care for Lung Transplant Recipients: A Multidisciplinary Approach

Lung transplantation has evolved as the gold standard for selective patients with end-stage lung disease since the first clinical lung transplant was performed in 1983 in the United States. Over the last few decades, lung transplantation volume has increased worldwide with steadily improving outcomes; however, access to lung transplantation remains limited due to the critical shortage of donor organs. Factors that have contributed to improved outcomes include a multidisciplinary management approach supported by advancements in surgical and anesthetic techniques, nursing and critical care, immunosuppressive therapy, transplant immunobiology, and the perioperative use of extracorporeal membrane oxygenation (ECMO) and ex vivo lung perfusion (EVLP). Excellent outcomes have been achieved in selective patients with high-risk comorbidities such as age over 65 years, concomitant severe coronary artery disease (CAD), and preexisting sensitization with donor-specific antibodies (DSAs). Such comorbidities are no longer considered absolute contraindications to lung transplantation. This chapter provides an overview of perioperative care of lung transplant recipients with focus on a multidisciplinary approach and highlights management strategies for patients with concomitant severe coronary artery disease and end-stage lung disease as well as those with preexisting sensitization with DSAs

Serum dilutions as a predictive biomarker for peri-operative desensitization: An exploratory approach to transplanting sensitized heart candidates.

Antibody-mediated rejection (AMR) of cardiac allografts mediated by anti-HLA Donor Specific Antibodies (DSA) is one of the major barriers to successful transplantation for the treatment of end-stage heart failure. Therapeutic plasma exchange (TPE) is a first-line treatment for pre-transplant desensitization. However, indications for treatment regimens and treatment end-points have not been well established. In this study, we investigated how sera dilutions could guide TPE regimens for effective peri-operative desensitization and early AMR treatment. Our data show that 1:16 dilutions of EDTA-treated sera and 1.5 volume TPE reduce anti-HLA class I and class II antibody levels in the same manner and, therefore, allows to predict which antibodies would respond to peri-operative TPE. We successfully applied this approach to transplanting three highly sensitized cardiac recipients (CPRA 85-93%) with peri-operative desensitization based on a virtual crossmatch performed on 1:16 diluted serum. Furthermore, we have used sera dilutions to guide DSA treatment post-transplant. Although these findings have to be confirmed in a larger prospective study, our data suggest that serum dilutions can serve as a predictive biomarker to guide peri-operative desensitization and post-transplant immunologic management