Jeremy R. Leonard

Both the open and endovascular techniques are commonly used for harvesting the radial artery (ORAH and ERAH, respectively), and yet, very little is known about the effects of these 2 techniques on endothelial integrity and function of the radial artery (RA). The aim of this study was to assess the endothelial integrity and function of RA harvested using the 2 approaches. Two independent surgical teams working in the same institution routinely use the RA for coronary artery bypass grafting exclusively employing either ORAH or ERAH. Thirty-nine consecutive patients were enrolled in this comparative study. Endothelial function after ORAH or ERAH was assessed by using the wire myograph system. The integrity of the RA endothelium was evaluated by immunohistochemical staining for erythroblast transformation specific-related gene. The vasodilation in response to acetylcholine was significantly higher in RA harvested with ORAH (P ≤ 0.001 versus ERAH). Endothelial integrity was not different between the 2 groups. ORAH is associated with a significantly higher endothelium-dependent vasodilation. Further investigation on the potential implications of these findings in terms of graft spasm and patency as well as clinical outcomes are needed.

Background Pulmonary artery aneurysms (PAAs) are a rare but potentially lethal cardiovascular pathology. PAAs tend to develop in young patients with no gender discrepancy; they are most often associated with congenital heart disorders but also with systemic infections, vasculitis, pulmonary arterial hypertension, chronic pulmonary embolism, and malignancies. Dissection and rupture carry significant morbidity and mortality, thus patients require careful management, especially those with associated pulmonary hypertension. Given the rarity of this condition, physicians have yet to establish standard treatment guidelines. Most studies published to date are case reports with one or two patients; here, we describe our experience with six cases of large PAAs treated surgically at our institution. Methods We identified and retrospectively analyzed clinical data for patients who underwent surgery for PAAs between 2009 and 2017. Results The average age at surgery was 59.73 years, five patients were females, and 83.3% had baseline hypertension. Systolic murmurs were the most common clinical finding. The average aneurysmal size was 65.0 mm. We repaired the PAA with a woven Dacron graft (22‐26 mm) in four patients. We performed concomitant pulmonary valve procedures on five patients: four replacements and one repair. Mean pump and cross‐clamp times were 108.5 and 65 minutes. Operative and 30‐day mortality was 0%. Average length of stay was 10.5 days. Conclusions Postoperative mortality was 0%; all patients showed improvement of symptoms after surgery. These findings confirm that PAA repair has an acceptable risk profile in select patients.

Objective Sinus of Valsalva (SOV) aneurysms are rare and data on operative management are limited. They can cause right ventricular outflow tract or pulmonary artery compression, and rupture may be fatal. In this study, we describe our experience with the repair of 13 SOV aneurysms. Methods All patients who underwent SOV aneurysm repair from May 2001 to December 2017 at our single tertiary referral center were reviewed retrospectively. Results Thirteen patients (92% male) with a mean age of 60 years underwent repair of an SOV aneurysm; mean aneurysm diameter was 5.9 ± 0.8 cm and four patients (30.7%) presented with rupture into another cardiac chamber. Operative interventions included six Bentall procedures, five patch repairs (one with aortic valve replacement [AVR]), and two primary aneurysm closures both with concomitant AVR. There were no strokes, myocardial infarctions, re‐explorations, or deaths in the postoperative period. After an average of 2.25 years, computed tomographic imaging in five patients demonstrated no aneurysm recurrence. Conclusions Surgery is a safe option for both ruptured and nonruptured SOV aneurysms. A variety of repair strategies may be used. Larger studies are needed.

Background AngioVac is a new device for filtering intravascular thrombi and emboli. Publications on the device are limited and underpowered to objectively estimate its safety and efficacy. We aimed to overcome this by performing a meta‐analysis on the results of AngioVac for treating venous thromboses and endocardial vegetations. Methods A systematic literature review was performed to identify all articles reporting cardiac vegetation and/or thrombosis extraction using AngioVac. Endpoints were successful removal, operative mortality, conversion to open surgery, hospital stay, recurrent thromboembolism, and follow‐up mortality. Random effect model was used, and pooled event rates (PERs) and incidence rate (IR) were calculated. Results A total of 42 studies with 182 patients (81 vegetation and 101 thrombosis) were included. Overall mean follow‐up times were 3.1 and 0.7 years in vegetation and thrombosis patients, respectively. The PERs for successful removal were 74.5 (confidence interval [CI]: 48.2‐90.2), 80.5 (CI: 70.0‐88.0), and 32.4 (CI: 17.0‐52.8) in vegetation, right atrial/caval venous thrombi, and pulmonary emboli (PE) patients, respectively. The PERs for operative mortalities were 14.6 (CI: 7.7‐25.8), 14.8 (CI: 8.5‐24.5), and 32.3 (CI: 15.1‐56.3), respectively. The PERs for conversion to open surgery were 25.0 (CI: 9.3‐51.9) and 12.3 (CI: 5.4‐25.6) in vegetation and thrombosis patients, respectively. The IR of recurrent thromboembolism was 0.18 per person per year (PPY) (CI: 0.00‐14.69) in vegetation and 0.19 PPY (CI: 0.08‐0.48) in thrombosis patients. IR of follow‐up mortality was 0.37 PPY (CI: 0.11‐1.21) in thrombosis patients. Conclusions AngioVac is a viable option for extracting right‐sided vegetations and right atrial/caval venous thrombi. Rates of successful extraction and mortality are significantly worse for PE.

Open repair of descending thoracic or thoracoabdominal aortic aneurysm (TAAA) continues to carry a not insignificant operative risk, even in experienced hands. Over the past three decades, there has been considerable improvement in both the mortality and morbidity associated with these procedures. Herein, we describe our operative results and long-term outcomes in patients with chronic type B aortic dissections.

Over the past three decades, there have been a plethora of retrospective observational data and meta-analyses which support the hypothesis of improved clinical outcomes using bilateral internal thoracic arteries (BITA) when compared to saphenous vein grafts (SVGs). However, recently published results have brought this thinking into doubt. We discuss the existing literature on the subject and attempt to clarify the appropriate use of BITA in coronary artery bypass surgery (CABG).

Background The radial artery (RA) is a frequently used conduit for coronary artery bypass graft (CABG). We review the results of the use of the RA in CABG patients and discuss the unique technical considerations when using this conduit. Methods A literature search was performed in PubMed through December 2017 on the comparative efficacy of the RA to other conduits and technical considerations for the use of the RA in CABG surgery. Results When compared to the saphenous vein graft, the RA proved to be superior in graft patency in multiple randomized clinical trials. The RA was associated with better clinical outcomes in observational studies. The debate over the second best arterial conduit remains unresolved between the RA and the right internal thoracic artery. Preoperative evaluation of the patient's coronary anatomy and the quality of the RA is imperative to achieve the best clinical outcome with RA grafting. Conclusion With careful preoperative planning and attention to technical details, the RA is an excellent choice as the second conduit for CABG surgery.

Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. POAF is associated with increased morbidity and hospital costs. We herein describe the protocol for a randomized controlled trial to determine if performing a posterior left pericardiotomy prevents POAF after cardiac surgery. All patients submitted to cardiac surgery at our institution will be screened for inclusion into the study. The study will consist of two parallel arms with random allocation between groups to either receive a posterior left pericardiotomy or serve as a control. Masking will be done in a single-blinded fashion to the patient. Patients will be continuously monitored postoperatively for the occurrence of atrial fibrillation until discharge. At the follow-up clinic visit (15–30 days after surgery), the primary endpoint (atrial fibrillation) and other secondary endpoints, such as pleural or pericardial effusion, will be assessed. A total sample size of 350 subjects will be recruited. POAF is associated with increased morbidity, prolonged hospital stay, and increased costs after cardiac surgery. Several strategies aimed at reducing the incidence of POAF have been investigated, including beta-blockers, amiodarone, and statins, all with suboptimal results. Posterior left pericardiotomy has been associated with a reduction of POAF in previous series. However, these studies had limited sample sizes and suboptimal methodology, so that the efficacy of posterior pericardiotomy in preventing POAF remains to be definitively proven. Our randomized trial aims to determine the effect of a posterior left pericardiotomy on the incidence of POAF. ClinicalTrials.gov, ID: NCT02875405 , protocol record 1502015867. Registered on July 2016.