Select Articles Published on the Topic of Cardiovascular Surgery in 2013
Journal: Circulation (2014)

A Aortic Dissection After Nonaortic Cardiac SurgerySummary-Nonaortic cardiac surgery is associated with a low but significant incidence of type A aortic dissection (AAD).Because there are important differences in clinical presentation, surgical management, and prognosis between spontaneous and late AAD following cardiac surgery, this large multicenter study sought to determine the conditions associated with the high surgical mortality of AAD repair as a complication of nonaortic cardiac surgery and to identify management pathways to improve outcome.We found that operative mortality depends on the type of initial surgery, time to AAD, and, importantly, influenceable management factors.AAD occurred mainly in patients with preexisting aortic wall pathology, identifiable with a slightly enlarged aorta, and hypertension at sites of iatrogenic mechanical trauma.This finding emphasizes most careful surgical handling and potentially a low threshold for prophylactic replacement of the ascending aorta that is without additional operative risk in experienced centers.Diagnosis of AAD warrants a mandatory high index of suspicion and depends primarily on imaging.The majority of patients with previous cardiac surgery had no or nonspecific symptoms when AAD was detected.The single most important factor that was associated with a lower operative mortality was implementation of preoperative coronary angiography and appropriate operative management of CAD and graft disease in patients with previous CABG.Because cardiac tamponade and hemodynamic instability are rare (1%), patients with previous cardiac surgery in stable condition should undergo preoperative native coronary and graft status assessment and appropriate operative planning, including aggressive revascularization and the use of deep hypothermic cardiac arrest.Conclusions-patients who have undergone previous cardiac surgery, preexisting aortic wall pathology contributes to AAD with typical intimal damage at sites of mechanical trauma.The operative mortality was the highest in patients with previous CABG in comparison with patients with non-CABG procedures.Preoperative coronary angiography and operative management of native coronary and graft disease were significantly associated with outcome in patients with previous CABG. 1 Fractional Flow Reserve-Guided Versus Angiography-Guided Coronary Artery Bypass Graft SurgerySummary-The data presented here might be clinically relevant in many respects.Although observational and limited in sample size, our study confirms that deferring revascularization on the basis of nonsignificant fractional flow reserve values even with bypass surgery is safe.This is particularly important if one considers that coronary artery bypass graft surgery is generally a once-in-a-lifetime operation.Therefore, surgeons are aiming at offering a complete revascularization with the best available vascular conduits.Leaving some of the stenoses with nonsignificant fractional flow reserve ungrafted did not show any excess hazard, whereas patients received mostly arterial grafts.This finding might contribute to the ongoing debate on less invasive or hybrid procedures; that is, once the left anterior descending coronary artery and other functionally significant stenoses are grafted with good arterial bypasses, remaining lesions, if they progress, could always be treated later with a good drug-eluting stent or vascular scaffold.Of course, this intriguing hypothesis needs to be tested prospectively in a randomized study.In this regard, our data provide a useful reference for sample size calculation and for the choice of the primary end point (clinical versus surrogate end point) for future trials.Conclusions-FFR-guided coronary artery bypass graft surgery was associated with a lower number of graft anastomoses and a lower rate of on-pump surgery compared with angiography-guided coronary artery bypass graft surgery.This did not result in a higher event rate during up to 36 months of follow-up and was associated with a lower rate of angina. 2