Influence of Ipsilateral Graft Inflow to Arteriovenous Fistula for Hemodialysis in Coronary Bypass Surgery

In coronary artery bypass grafting (CABG) for patients on hemodialysis, there has been concern about “coronary steal”. This study aims to evaluate the influence of using an in situ internal thoracic artery (ITA) ipsilateral to a preexisting arteriovenous fistula (AVF) in dialysis-dependent patients undergoing CABG. Between 2004 and 2018, dialysis-dependent patients with AVFs who underwent CABG were enrolled. According to the locational relationship of AVFs and in situ ITA grafts, the patients were divided into the ipsilateral group (n = 22) and the contralateral group (n = 21). Inverse probability weighting analysis was used to estimate and compare the late clinical outcomes. The late cardiac-related adverse events were not significantly different between the two groups: “major adverse cardiovascular and cerebrovascular events (MACCE)” (p = 0.090), “composite outcome of recurrent angina and coronary re-intervention” (p = 0.600). The in situ ITA graft of CABG on the ipsilateral side to AVF was not a significant risk factor for MACCE or the composite outcome of recurrent angina and coronary re-intervention. There was no statistically significant difference in the graft patency between the groups. Therefore, it might not be necessary to avoid using an in situ ITA on the ipsilateral side of an upper-arm AVF for optimal coronary artery bypass grafting in dialysis-dependent patients

Aortic Valve Replacement for Aortic Stenosis in Elderly Patients (75 Years or Older)

Background: This study evaluated the early and long-term outcomes of surgical aortic valve replacement (AVR) in elderly patients in the era of transcatheter aortic valve implantation. Methods: Between 2001 and 2018, 94 patients aged ≥75 years underwent isolated AVR with stented bioprosthetic valves for aortic valve stenosis (AS). The main etiologies of AS were degenerative (n=63) and bicuspid (n=21). The median follow-up duration was 40.7 months (range, 0.6-174 months). Results: Operative mortality occurred in 2 patients (2.1%) and paravalvular leak occurred in 1 patient. No patients required permanent pacemaker insertion after surgery. Late death occurred in 11 patients. The overall survival rates at 5 and 10 years were 87.2% and 65.1%, respectively. The rates of freedom from valve-related events at 5 and 10 years were 94.5% and 88.6%, respectively. The Society of Thoracic Surgeons (STS) score (p=0.013) and chronic kidney disease (p=0.030) were significant factors affecting long-term survival. The minimal p-value approach demonstrated that an STS score of 3.5% was the most suitable cut-off value for predicting long-term survival. Conclusion: Surgical AVR for elderly AS patients may be feasible in terms of early mortality and postoperative complications, particularly paravalvular leak and permanent pacemaker insertion. The STS score and chronic kidney disease were associated with long-term outcomes after AVR in the elderly

Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery

© 2022, The Korean Society for Thoracic and Cardiovascular SurgeryBackground: Robot-assisted repair of atrial septal defect (ASD) can be performed under either beating-heart or non-beating-heart conditions. However, the risk of cerebral air embolism (i.e., stroke) is a concern in the beating-heart approach. This study aimed to compare the outcomes of beating and non-beating-heart approaches in robot-assisted ASD repair. Methods: From 2010 to 2019, a total of 45 patients (mean age, 43.4±14.6 years; range, 19–79 years) underwent ASD repair using the da Vinci robotic surgical system. Twenty-seven of these cases were performed on a beating heart (beating-heart group, n=27) and the other cases were performed on an arrested or fibrillating heart (non-beating-heart group, n=18). Cardiopulmonary bypass (CPB) was achieved via cannulation of the femoral vessels and the right internal jugular vein in all patients. Results: Complete ASD closure was verified using intraoperative transesophageal echocardiography in all patients. Conversion to open surgery was not performed in any cases, and there were no major complications. All patients recovered from anesthesia without any immediate postoperative neurologic symptoms. In a subgroup analysis of isolated ASD patch repair (beating-heart group: n=22 vs. non-beating-heart group: n=5), the operation time and CPB time were shorter in the beating-heart group (234±38 vs. 253±29 minutes, p=0.133 and 113±28 vs. 143±29 minutes, p=0.034, respectively). Conclusion: Robot-assisted ASD repair can be safely performed with the beating-heart approach. No additional risk in terms of cerebral embolism was found in the beating-heart group.N

Influence of Ipsilateral Graft Inflow to Arteriovenous Fistula for Hemodialysis in Coronary Bypass Surgery

In coronary artery bypass grafting (CABG) for patients on hemodialysis, there has been concern about "coronary steal". This study aims to evaluate the influence of using an in situ internal thoracic artery (ITA) ipsilateral to a preexisting arteriovenous fistula (AVF) in dialysis-dependent patients undergoing CABG. Between 2004 and 2018, dialysis-dependent patients with AVFs who underwent CABG were enrolled. According to the locational relationship of AVFs and in situ ITA grafts, the patients were divided into the ipsilateral group (n = 22) and the contralateral group (n = 21). Inverse probability weighting analysis was used to estimate and compare the late clinical outcomes. The late cardiac-related adverse events were not significantly different between the two groups: "major adverse cardiovascular and cerebrovascular events (MACCE)" (p = 0.090), "composite outcome of recurrent angina and coronary re-intervention" (p = 0.600). The in situ ITA graft of CABG on the ipsilateral side to AVF was not a significant risk factor for MACCE or the composite outcome of recurrent angina and coronary re-intervention. There was no statistically significant difference in the graft patency between the groups. Therefore, it might not be necessary to avoid using an in situ ITA on the ipsilateral side of an upper-arm AVF for optimal coronary artery bypass grafting in dialysis-dependent patients.N

Changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection

OBJECTIVES: The aim of this study was to evaluate changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection (ABAD). METHODS: Medically treated patients with uncomplicated ABAD between September 2004 and January 2020 were retrospectively reviewed. Diameters of 6 different sites in the descending aorta were measured and aortic growth rate was calculated according to the time interval. Factors associated with aneurysmal changes were also investigated. RESULTS: This study enrolled a total of 105 patients who underwent >2 serial computed tomography with a mean follow-up duration of 35.4 (12.1-77.4) months. The mean overall growth rates of the proximal descending thoracic aorta (DTA), mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA and maximal abdominal aorta were 0.6 (1.9), 2.9 (5.2), 2.1 (4.0), 1.2 (2.2), 3.3 (5.6) and 1.4 (2.5) mm/year, respectively. The growth rate was higher at the early stage. It decreased over time. Growth rates of proximal DTA, mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA, and maximal abdominal aorta within 3 months after dissection were 1.3 (9.6), 12.6 (18.2), 7.6 (11.7), 5.9 (7.5), 16.7 (19.8) and 6.8 (8.9) mm/year, respectively. More than 2 years later, they were 0.2 (0.6), 1.6 (1.6), 1.2 (1.3), 0.9 (1.4), 1.7 (1.9) and 1.2 (1.7) mm/year, respectively. Factors associated with aneurysmal changes after uncomplicated ABAD included an elliptical true lumen (odds ratio = 3.16; 95% confidence interval: 1.19-8.41; P = 0.021) and a proximal entry >10 mm (odds ratio = 3.08; 95% confidence interval: 1.09-8.69; P = 0.034) on initial computed tomography imaging. CONCLUSIONS: The aortic growth rate was higher immediately after uncomplicated ABAD but declined eventually. Patients with an elliptical true lumen and a large proximal entry might be good candidates for early endovascular intervention after uncomplicated ABAD.N