Surgical Myocardial Revascularization in a Sub-Saharan African Country: Indications and Results

Introduction: Despite the advances of interventional catheterization, surgery remains the treatment of choice for some coronary lesions. Objective: To report the indications and results of surgical revascularization of the myocardium at the Abidjan Heart Institute. Patient and Methods: This is a retrospective study of patients with coronary insufficiency who underwent surgical myocardial revascularization between March 2014 and May 2020 in the Cardiovascular Surgery Department of the Abidjan Heart Institute. There were 17 patients, 11 of whom were men (64.7%) and 6 women (35.3%), The mean age of the patients was 57.5 years ± 8.8. All patients were symptomatic with disabling angina in class III of the Canadian Cardiac Society (CCS). This sym- ptomatology had been evolving on average for 5 years and 6 patients had a history of acute coronary syndrome, 2 of whom had undergone prior angioplasty. Coronary angiography revealed mono-truncated (17.6%), bi-truncated (23.5%) and tri-truncated (58.8%) lesions. Results: The patients were operated under cardiopulmonary bypass (CPB) 15 cases (88.2%) and off pump in 2 cases (11.8%). They underwent a single bypass in 23.5% of cases, a double bypass in 47.1% of cases and a triple bypass in 29.4% of cases. We observed 3 cases of complications (17.6%), namely transient acute renal failure, mediastinitis and postoperative bleeding. The operative and hospital mortality was nil. After a mean follow-up of 3 ± 1.8 years, all patients were asymptomatic with a negative stress test at last check-up. Conclusion: Our experience has allowed us to demonstrate the safe performance of surgical myocardial revascularization in our patients with satisfactory and encouraging results.

Viable Myocardium Impact on Left Ventricular Function after Late Revascularization of Infarct-related Artery in Acute Myocardial Infarction

Objectives The long-term benefit of late reperfusion of infarct-related artery （IRA） after acute myocardial infarction （AMI） is controversial, and the benefit mechanisms remain uncertain. Low dose dobutamine stress echocardiography （LDSE） can identify viable myocardium and predict improvement of wall motion after revascularization. Methods Sixtynine patients with first AMI who did not received early reperfusion therapy were studied by LDSE at 5 to 10 days after AMI. Wall motion abnormality and left ventricular size were measured at the same time. Successful PCI were done in all patients at 10 to 21 days after AMI onset. Patients were divided in two groups based on the presence or absence of viable myocardium. Echocardiography was repeated six months later. Results There were 157 motion abnormality segments. 89 segments （57%） were viable during LDSE. 26 patients （38%） with viability and 43 （62%） without. In viable group, left ventricular ejection fraction （LVEF） was increased （P 〈 0.05）, and left ventricular end systolic volume index （LVESVI） and wall motion score （WMS） were decreased （P 〈 0.05 and P 〈 0.01） significantly at 6 months compared with baseline. But in patients without viability, LVEF was decreased （P 〈 0.01）, and LVESVI and left ventricular end diastolic volume index （LVEDVI） were increased （P 〈 0.05） significantly after 6 months, and the WMS did not changed （P 〉 0.05 ）. LVEF increased （P 〈 0.05 ） and WMS decreased （P 〈 0.05） on LDSE during acute phase in patients with viability, but they were not changed in the nonviable group. Conclusions Late revascularization of IRA in patients with presence of viable myocardium after AMI is associated with long-term preservation left ventricular function and less ventricular remodeling. Improvement of left ventricular systolic function on LDSE indicates late phase recovery of left ventricular function after late revascularization.

Off-pump coronary artery bypass grafting versus optimal medical therapy alone：effectiveness of incomplete revascularization in high risk patients

BackgroundGeriatric patients with multivessel coronary artery disease （CAD） are a challenging group to treat; these cases elicit dis-cussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass （OPCAB） provides good quality graft on left anterior descending （LAD） without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy.MethodsWe retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included： 42 were treated with incomplete off-pump revascularization using left internal mammary artery （LIMA） on LAD; 41 were discharged in optimal medical therapy （OMT）, having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events （MACEs）.ResultsDuring follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those dis-charged in OMT （Log Rank ＆lt; 0.001）, and OMT group carries a propensity score-adjusted hazard ratio of 3.862 （P ＆lt; 0.001）. With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT （Log Rank = 0.002）, and OMT group carries a propensity score-adjusted hazard ratio of 3.663 （P = 0.010）. There is no statistically significant difference concerning freedom from MACEs （Log Rank = 0.273）.ConclusionsFor high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.

Minimally invasive surgical techniques in the era of hybrid coronary revascularization： additional benefits for the elderly patients？

Geriatric patients affected by stable multi-vessel coronary artery disease （CAD） are at the crossroad： they can live with the risks of acute coronary syndrome, malignant arrhythmias or heart failure, or they can undergo a rapid evaluation for myocardial revascularization.

Research of transmyocardial stent to treatacute myocardial infarction

Objectives To explore the feasibility, safety and efficacy of transmyocardial stent to treat acute myocardial infarction. Methods 24 Chinese mini swines have been divided into 2 groups randomly：group myocardial infarction （group MI n1 = 14） and group transmyocardial stent（group ST n2 = 10）. In group MI, acute myocardial infarction animal model has been established by the ligation of the left descending coronary artery. In group ST, after the establishment of the model, 3 transmyocardial stents were implanted. 4 weeks later, echocardiography and pathological analysis have been done. Results The density of blood vessel in group ST is 6.47 ± 0.60/HP which is significandy higher than the group MI. At the same time, left ventricular ejection fraction and regional wall motion score index （WMSI） in group ST are ameliorated significandy compared with group MI. Conclusion It is feasible and safe to implant transmyocardial stents in acute myocardial infarction model. Although the channel can＇ t remain patent in long term, the prolonged stimulation can cause moderate-serious inflammatory reaction and proficient angiogenesis.

Trimetazidine and Cellular Response in Cardiopulmonary Bypass

Background: Organic cellular inflammatory response constitutes a pathophysiological mechanism present in all Coronary Artery Bypass Graftings (CABGs). In this aspect, the organism brings forth its defenses through answers that involve cellular components. Objectives: To evaluate, in a randomized double-blind prospective study, controlled with placebo, the effects of trimetazidine (Tmz) on cellular response, analyzed through the variation of leukocytes, neutrophils and monocytes. Patients and Method: 30 patients were randomly selected to be studied, with no more than a mild ventricular dysfunction, and divided into two groups (Tmz and placebo) stratified by echocardiography and receiving medication/placebo in a 60 mg/day dose. The samples of leukocytes, neutrophils and monocytes were obtained in the pre-operatory day without medication, at surgery day with 12 to 15 days of medication/placebo, with 5 minutes after the aortic declamping, and within 12, 24 and 48 hours after surgery. Results: The leukocytes and neutrophils levels have decreased significantly in the treated group when compared to the control group, in all analyzed moments (p = 0.012;p = 0.005). Conclusions and Clinical Implications: Trimetazidine has proved to reduce significantly the levels of total leukocytes and neutrophils in patients submitted to CABG.

Emergency off-pump coronary artery surgery

Background Off-pump coronary artery bypass grafting is fast-becoming a procedure of choice for elective revascularization in high-risk patients with multi-vessel coronary artery disease. However,the role of off-pump coronary artery bypass grafting for patients with acute coronary syndromes requiring emergency revascularization still requires validation. We present our experience to show the feasibility of off-pump coronary artery surgery as an emergency revascularization technique. Methods From April 2001 to September 2003,emergency (operation within 24 hours after hospitalization) coronary artery bypass grafting without cardiopulmonary bypass (CPB) was performed in 66 patients with a mean age of (66.9±5.4) years (range 49-72 years). They presented acute coronary syndromes with 38 patients on platelet glycoprotein Ⅱb/Ⅲa receptor antagonists. All patients underwent off-pump coronary artery bypass surgery via sternotomy with the intention of complete coronary revascularization.Results An average of 2.9 grafts per patient were performed and the posterior descending artery and marginal branches of the circumflex artery were grafted in 83.3% of the patients. There were 4 events of intraoperative cardiac instability, precipitated by occlusion of right coronary artery or positioning of a cardiomegaly heart,leading to immediate conversion to CPB. The mortality rate was 3% (2/66). Two patients suffered postoperative stroke while three needed hemofiltration for acute renal failure. Post surgery elective coronary angiography (n=46) showed no significant stenosis.Conclusion Emergency off-pump coronary artery surgery with complete revascularization is feasible in patients with acute coronary syndrome with low morbidity and mortality and excellent early results.