Percutaneous coronary intervention is the first choice for treating simple coronary artery lesions because of the progress of coronary stents in recent years. Coronary artery bypass grafting is recommended for patients with multiple, diffuse and severely diseased coronary lesions. The most important goals of coronary artery bypass grafting are complete revascularization and long-term graft patency without reintervention. The left internal thoracic artery has demonstrated superior graft patency and provided excellent clinical results compared with saphenous vein graft. Moreover, bilateral internal thoracic artery grafting has better survival benefits than single internal thoracic artery grafting and patency rates and survival benefits are satisfactory when bilateral internal thoracic artery grafts are used. However, bilateral internal thoracic artery use rate remains low for reasons including the complexity of graft configuration and risk of sternal wound infection. This review aims to address the advantages and disadvantages of using the bilateral internal thoracic artery in coronary artery bypass grafting.
Myocardial contrast echocardiography (MCE) is an imaging modality to visualize myocardial perfusion using gas-filled microbubbles. Ultrasound contrast agents containing microbubbles are usually administered intravenously, and small microbubbles flow into left heart through pulmonary circulation. Number of microbubbles flowing into microcirculation would be very small, and image enhancing techniques such as intermittent power Doppler are required to detect weak signal from intramyocardial microbubbles. Fragile microbubbles are easily destroyed by incident ultrasound. When contrast agent is administered by continuous intravenous infusion, microbubbles are replenished into capillaries after microbubble destruction by ultrasound pulse. By analyzing the temporal recovery of myocardial contrast enhancement after microbubble destruction (a replenishment curve), myocardial blood flow could be determined. Such quantitative analysis can be performed using intermittent imaging technique or real-time MCE at low mechanical index (MI) ultrasound. MCE detects microvascular dysfunction (no-reflow phenomenon) in patients with acute myocardial infarction, which determines functional and clinical outcomes. MCE using stress testing could detect myocardial ischemia in patients with coronary artery disease (CAD). Theoretically, MCE could detect endocardial ischemia and diagnose CAD better than single-photon emission computed tomography (SPECT) because of higher spatial resolution. However, large-scale clinical studies failed to demonstrate superiority of MCE to SPECT for detecting CAD. No contrast agent is still approved for MCE, and further improvement of microbubbles and imaging techniques is required.
Patients with a dilated left ventricle (LV) represent a high-risk group for developing heart failure after myocardial infarction. The procedure of surgical ventricular reconstruction (SVR) was developed to reduce ventricular volume through scar exclusion. Although the results of the Surgical Treatment for Ischemic Heart Failure (STICH) have cast doubt on the clinical benefits of SVR concomitant with revascularization, subanalysis of the STICH results showed that appropriately selected patients could benefit from SVR.(br)In this review, we examined the report of SVR and investigated which patients could be most eligible for SVR to improve their prognosis concomitant with revascularization. We performed this examination from the point of view of optimum volume, shape, and viability, mainly examining the STICH subanalysis; along with this, we examined the future direction of SVR.
Objective: Although untreated post-infarction ventricular septal defect (VSD) in acute phase has a high mortality rate, surgeons are reluctant to perform emergent surgery due to fragility of the infarcted myocardium. We have reported the “sandwich technique,” via a right ventricular (RV) incision, to treat a post-infarction VSD even in the ultra-acute phase. This technique involves the placement of patches on both sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches; the surgical adhesive fixes and strengthens the fragile infarcted tissue. One-year mortality was found to be related to a major residual leak. In this study, we attempted to determine the location of the leak after the repair using the sandwich technique via an RV incision to treat post-infarction VSD. Materials and Methods: We evaluated 27 consecutive patients with post-infarction VSD who underwent repair using the “sandwich technique” via an RV incision in our series. The location of the major leak was divided into eight segments around the VSD. Results: The mean duration from onset to operation was 2.0 days, with 78% of patients being operated in two days and 96% patients operated in one week. The 30-day mortality rate was 4%, and 1-year mortality rate was 30%. The segments were divided into four areas: apical area (6/13, 46%), free wall side area (3/13, 23%), cranial area (3/13, 23%), and septal area (1/13, 8%). Conclusion: The location of the leak seemed to be related to the ischemic myocardial damage depending on the absence of collateral circulation. Surgical strategy should be established to prevent and repair residual leak.
The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis. We report a young adult patient of APS associated with systemic lupus erythematosus (SLE), who underwent off pump coronary artery bypass grafting for angina pectoris. She had been diagnosed with SLE at 12 years of age. Two years later, she suffered from right thalamencephalon infarction and was diagnosed as having antiphospholipid syndrome (APS) based on elevation of anticardiolipin antibodies. During twelve years until 26 years old, various thromboembolic and bleeding events occurred in the patient. At 30 years of age, she admitted to our hospital with high fever and the computed tomography detected de-novo cerebral arterial aneurysm. This suggested active vasculitis. On this admission, the ST pattern in the electrocardiogram was changed. Severe stenosis of left anterior descending coronary artery (LAD) and total occlusion of right coronary artery (RCA) were identified by coronary angiography (CAG). We performed off pump coronary artery bypass using saphenous vein grafts because of occlusion of bilateral intrathoracic arteries. The postoperative course was uneventful without any thromboembolic and bleeding complications. Postoperative CAG showed good patency of both vein grafts to LAD and RCA.