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T A Salerno

Publications and source records attributed to T A Salerno.

At least 19 recordsLinked to original sources
PubMed2004

The role of beating heart coronary artery bypass grafting in the current era: a point of view.

Despite coronary artery revascularization on the beating heart was originally introduced in the 1960's, its further development was halted for several decades by advances in medical technology and by the development of the extracorporeal circulation. It is only in recent years that coronary artery bypass grafting on the beating heart has gained a secure role in the armamentarium of cardiac surgeons, mainly as a result of the popularization of new techniques of coronary exposure and stabilization. In later years, the expansion of interventional cardiology and the refinement of catheter-based techniques for treating coronary artery disease have corresponded to a substantial decline in the overall number of patients referred for surgery. Additionally, more and more patients have extensive disease and concomitant risk factors. These factors have made the future of coronary artery surgery uncertain. As these trends are likely to persist, and probably become more prominent in the future, it is essential for surgeons to embrace changes that may lead to improved surgical outcomes after coronary revascularization. In this article the authors review some of the aspects that have contributed to the popularization of off-pump coronary artery bypass and speculate on the importance of embracing innovative techniques in the field of coronary artery surgery.

Aged↗
PubMed2001

Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach.

Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.

Humans↗
PubMed2001

Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient.

Cardiac surgery is perceived to be maximally invasive and fraught with complications. Secondary to this, cardiothoracic surgeons have been refining traditional techniques to minimize their invasive nature. Epidural anesthesia has been utilized safely and effectively for numerous surgical procedures to reduce the associated morbidity. In hopes of achieving a similar result, we utilized thoracic epidural anesthesia for a coronary artery bypass via a left anterior thoracotomy, in an awake, spontaneously breathing patient. To the best of our knowledge, this is the first reported case utilizing this approach. Herein we report the results and technique utilized.

Anesthesia, Epidural↗
PubMed2001

Surgical strategy for repair of large pseudoaneurysms of the aortic isthmus.

Resection of unusually large pseudoaneurysms of the aortic isthmus is complex, and involves various strategies of cardiopulmonary bypass (CPB), cerebral and spinal cord protection. We report on a patient with a giant pseudoaneurysm of the distal arch and proximal descending aorta, in whom cannulation of the femoral artery was unfeasible. Instead, the right axillary artery and the left femoral vein were cannulated. This technique allowed to perform a left anterolateral thoracotomy with the patient already on CPB and hypothermic, and to shorten the duration of hypothermic circulatory arrest.

Aneurysm, False↗
PubMed2001

"Single suture" for exposure of the heart in left ventricular assist device placement.

Using the "single suture" technique described for exposure of the heart during off-pump coronary surgery, all surfaces of the heart may be exposed with little hemodynamic compromise. Using this technique, the apex of the heart is easily elevated for left ventricular assist device (LVAD) insertion in patients with either ischemic or dilated cardiomyopathy. This technique may provide the groundwork for routine placement of LVADs without the use of cardiopulmonary bypass.

Cardiomyopathy, Dilated↗
PubMed2001

Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?

BACKGROUND: The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques. METHODS: The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups. RESULTS: Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients. CONCLUSIONS: Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a threefold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.

Adult↗
PubMed2000

The innominate artery as an inflow site in coronary reoperations without cardiopulmonary bypass.

The innominate artery was used as an inflow site in 20 patients undergoing redo coronary operations without cardiopulmonary bypass. This technique was adopted when extensive adhesions and old patent grafts were present, to avoid dissection of the ascending aorta and eliminate the risk of graft injury or embolization. This strategy considerably facilitated construction of proximal anastomoses and was associated with favorable perioperative outcomes.

Brachiocephalic Trunk↗
PubMed2000

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass.

BACKGROUND: Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians. METHODS: Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared. RESULTS: The groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant). CONCLUSIONS: This investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.

Age Factors↗
PubMed2000

Reoperative "off-pump" circumflex revascularization via left thoracotomy: how to prevent graft kinking.

Reoperative circumflex revascularization can be performed through a left thoracotomy approach, with or without cardiopulmonary bypass. In such cases, establishing the appropriate length of coronary grafts connecting the descending thoracic aorta to one of the marginal branches of the circumflex coronary artery may be problematic. In fact, if these grafts are too long they may kink, whereas if left too short they may be injured by respiratory excursions of the left lower lobe of the lung. In this report we describe a technique that can prevent these potential complications.

Humans↗
PubMed2000

Survey of resident training in beating heart operations.

BACKGROUND: "Off-pump" coronary artery operations are done with increasing frequency in the treatment of coronary artery disease. As a result, residents in thoracic surgery have been confronted with the necessity of gaining experience in this innovative approach to coronary surgery. The aim of this study was to assess the importance of training in minimally invasive coronary revascularization as it was perceived by thoracic surgery residents. METHODS: A postal, multiple-choice survey questionnaire was sent to all cardiothoracic surgery residents (n = 327) of accredited training programs in the United States. Responses were tabulated and analyzed. RESULTS: The overall response rate was 68% (222 of 327 residents). The attending staff was very interested (37%), or had some interest (63%), in beating heart coronary revascularization. Ninety-eight percent of the programs had at least one surgeon performing off-pump procedures. Although 88% of the responding residents showed some interest in off-pump coronary operations, only 22% of them had performed more than 20 off-pump cases, and even less (12%) had performed more than 20 cases of off-pump complete revascularization, or off-pump circumflex revascularization (4%). Sixteen percent of them had no clinical experience with these techniques. Regarding career intentions, 88% of the residents indicated that off-pump coronary operations were expected to be part of the practice, and 58% of them were interested in pursuing additional training in less invasive heart procedures. CONCLUSIONS: The results of this survey suggest that training in off-pump coronary revascularization is variable across training programs, and that the majority of residents may not reach proficiency in coronary procedures on the beating heart during their residency. This may adversely affect their future expectations, as 88% of them would like to practice off-pump coronary surgery once the training is completed.

Cardiopulmonary Bypass↗
PubMed2000

Manubrium-sparing sternotomy and off-pump coronary artery bypass grafting in patients with tracheal stoma.

The presence of a tracheal stoma in patients with previous total laryngectomy who require cardiac operations is associated with an increased risk of wound complications and tracheal injuries when a full sternotomy is used. The aim of this report is to describe a technique of manubrium-sparing sternotomy, which can be used in patients undergoing coronary artery bypass grafting without cardiopulmonary bypass.

Coronary Artery Bypass↗
PubMed2000

Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta.

Endovascular stent graft repair of descending thoracic aortic aneurysms has been recently introduced as an alternative to conventional graft replacement of the diseased aorta. As experience with this new technique accumulates, complications may occur. We herein report the case of a patient in whom we observed distal migration with leak of an endovascular stent graft previously inserted in the descending thoracic aorta, associated with an aortobronchial fistula. The urgent surgical treatment undertaken, which consisted of graft replacement of the previously stented aorta, had a fatal outcome.

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