Objective: Multivessel minimally invasive coronary artery bypass grafting, performed chiefly with left internal thoracic artery and saphenous vein grafts through a left anterolateral thoracotomy, has recently emerged as an alternative to conventional coronary artery bypass grafting. The present study involves our initial experience with respect to early postoperative and angiographic outcomes after total arterial multivessel off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries.Methods: A total of 88 consecutive patients undergoing total arterial off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries without ascending aortic manipulation were included in this study. Bilateral internal thoracic arteries were harvested under direct vision through a left anterolateral thoracotomy and used as Y or in situ grafts. Multivessel grafting was performed off pump. Postoperative graft assessment was performed in 51 patients.Results: The mean age of patients was 67.1 AE 7.2 years, and 79 patients (89.8%) were male. The mean body mass index and ejection fraction were 26.7 AE 2.7 kg/ m 2 and 57.6% AE 6.6%, respectively, and 40 patients (45.5%) had left main disease. No intraoperative conversions to cardiopulmonary bypass or sternotomy occurred. A total of 209 distal anastomoses (mean 2.4 AE 0.5) were performed, with 57 patients undergoing double, 29 patients undergoing triple, and 2 patients undergoing quadruple coronary artery bypass grafting. There was no in-hospital mortality, and 5 patients underwent reexploration for bleeding. No patient had stroke or chest wound infections. Predischarge coronary angiography revealed an overall graft patency rate of 96.8%.Conclusions: Off-pump minimally invasive coronary artery bypass grafting using total arterial revascularization with bilateral internal thoracic arteries is a feasible and safe operation that is associated with excellent short-term outcomes and early graft patency. Future studies should focus on improving the generalizability and reproducibility of this technique.

Background— To analyze the effect of immediate treatment of perioperative myocardial ischemia (PMI) because of early graft failure or incomplete revascularization in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods and Results— Between January 2004 and December 2010, 7461 patients underwent isolated CABG at our institution. All patients showing evidence of PMI (n=399; 5.3% of total) underwent emergent coronary angiography. A total of 900 grafts and 1061 distal anastomoses were examined. Two hundred fifty-five patients had 360 distal anastomoses compromised because of early graft failure or incomplete revascularization (ie, abnormal postoperative coronary angiogram). Revision CABG or percutaneous coronary intervention was performed in 130 (51.0%) and 34 (13.3%) patients with abnormal angiograms, respectively. Nonsurgical therapy was implemented in the remaining 91 patients (35.7%) with abnormal angiograms. One hundred forty-four patients had normal postoperative graft-related angiograms. In-hospital mortality was 7.3% and 2.9% in patients with and without PMI ( P <0.001). In patients with PMI, in-hospital mortality was 9.4% and 3.5% in patients with abnormal and normal postoperative angiograms, respectively ( P =0.03). Significant multivariable predictors of in-hospital mortality were hemodynamic deterioration, preangiography creatine kinase-MB isoenzyme rise >2× normal, and time interval between primary CABG and coronary angiography >30 hours. Five-year survival in patients without PMI (85.7±0.5%) was significantly better than those with PMI and abnormal angiograms (74.9±2.9%; P <0.001 log-rank). When in-hospital mortality was excluded, however, this difference in midterm survival disappeared ( P =0.9). Conclusions— PMI is associated with increased in-hospital mortality in patients undergoing isolated CABG. Expeditious management of bypass graft failure results in similar midterm survival to nonischemic patients in hospital survivors.

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OBJECTIVES Non-leaflet resection techniques including loop chordal replacement are being used with increasing frequency, but the long-term results of these techniques are still unknown. The aim of this study was to compare the long-term results of loop neochord replacement with leaflet resection techniques in patients undergoing minimally invasive mitral valve (MV) repair for MV prolapse. METHODS Between 1999 and 2014, 2134 consecutive MV prolapse patients underwent minimally invasive MV repair with isolated loop (n = 1751; 82.1%) or resection techniques (n = 383, 17.9%) at our institution. Follow-up data were available for 86% of patients with a mean follow-up time of 6.1 ± 4.3 years. RESULTS The 30-day mortality was 0.8% for all patients (loop: 0.7%, resection: 1.6%; P = 0.09). Leaflet resection was associated with more moderate or more mitral regurgitation on predischarge echocardiography (P = 0.003). The 1-, 5- and 10-year survival rates were 98 ± 1%, 95 ± 1% and 86 ± 2% for the loop technique versus 97 ± 1%, 92 ± 1% and 81 ± 2% for resection patients, respectively (P = 0.003). Significant predictors for late mortality were MV repair technique (P = 0.004), left ventricular ejection fraction (P &lt; 0.001), age (P &lt; 0.001) and myocardial infarction (P &lt; 0.001). Freedom from MV reoperation at 1, 5 and 10 years was 98 ± 1%, 97 ± 1%, 97 ± 1% and 97 ± 1%, 97 ± 1%, 96 ± 1% for patients operated on with the loop technique and leaflet resection (P = 0.4). CONCLUSIONS In our patient cohort, MV repair with loop chordal replacement is associated with less early recurrent mitral regurgitation and very good long-term results when compared to classical leaflet resection techniques for MV prolapse and is therefore an excellent option for such patients.

Background-Current guidelines do not provide recommendations for optimal timing of coronary artery bypass surgery (CABG) in patients with non-ST-segment-elevation myocardial infarction. Our study aimed to determine the impact of CABG timing on early and late outcomes in patients with non-ST-segment-elevation myocardial infarction. Methods and Results-A total of 758 patients underwent CABG within 21 days after non-ST-segment-elevation myocardial infarction between January 2008 and December 2012 at our institution. The patients were divided into 3 groups according to the time interval between symptom onset and CABG: group A, <24 hours (133 patients); group B, 24 to 72 hours (192 patients); and group C, >72 hours to 21 days (433 patients). Predictors of in-hospital and long-term mortality were identified by logistic and Cox regression analyses, respectively. Overall in-hospital mortality was 5.1% (39 patients): 6.0%, 4.7%, and 5.1% in groups A, B, and C (P=0.9), respectively. A total of 118 patients died during follow-up. The 5-year survival was 73.1±2%, with a nonsignificant trend toward better survival in groups A (78.2±4%) and C (75.4±3%) compared with group B (63.6±5%; log-rank P=0.06). Renal insufficiency and LMD were independent predictors of in-hospital (odds ratio, 3.1; P=0.001; and odds ratio, 3.1; P=0.002) and long-term mortality (hazard ratio, 1.7; P=0.004; and hazard ratio, 1.5; P=0.02), whereas administration of P2Y 12 inhibitors was protective (odds ratio, 0.3; P=0.01). Conclusions-Emergent CABG within 24 hours of non-ST-segment-elevation myocardial infarction is associated with in-hospital mortality and long-term outcomes similar to those of CABG performed after 3 days, despite a higher risk profile. CABG performed between 24 to 72 hours showed a nonsignificant trend toward poorer long-term outcomes. Dual antiplatelet therapy until surgery is beneficial, whereas renal insufficiency and left main disease increase the risk of early and late death. (Circulation. 2015;132:731-740.