ObjectivesUpdated knowledge about perioperative myocardial ischaemia (MI) after coronary artery bypass grafting (CABG) and treatment of acute graft failure is needed. We analysed main factors associated with perioperative MI and effects of immediate coronary angiography-based treatment strategy on patient outcome.MethodsAmong 1119 consecutive patients with coronary artery disease who underwent isolated CABG between January 2011 and December 2015, 43 (3.8%) patients underwent urgent coronary angiography due to suspected perioperative MI. All the data were prospectively collected and retrospectively analysed. The primary endpoint was 30-day mortality; postoperative left ventricular ejection fraction) and major adverse cardiac events were secondary endpoints.ResultsOverall, 30-day mortality in patients with CABG was 1.4% while in patients who developed perioperative MI was 9% (4 patients). Angiographic findings included incorrect graft anastomosis, graft spasm, dissection, acute coronary artery thrombotic occlusion and ischaemia due to incomplete revascularisation. Emergency reoperation (Redo) was performed in 14 (32%), acute percutaneous coronary intervention (PCI) in 15 (36%) and conservative treatment (Non-op) in 14 patients. Demographic and preoperative clinical characteristics between the groups were comparable. Postoperative LVEF was significantly reduced in the Redo group (45% post-op vs 53% pre-op) and did not change in groups PCI (56% post-op vs 57% pre-op) and Non-op (58% post-op vs 57% pre-op).ConclusionsUrgent angiography allows identification of the various underlying causes of perioperative MI and urgent treatment when this is needed. Urgent PCI may be associated with improved clinical outcome in patients with early graft failure.

A 38-year-old Marfanoid male was evaluated for an aortic root false aneurysm. Five years previously, he presented with severe aortic insufficiency, a 9.4-cm ascending aortic aneurysm, severe mitral regurgitation, and a coarctation of the aorta just distal the origin of the left subclavian artery. At the time of surgery, the aortic root was replaced with a #29-mm St. Jude mechanical composite graft (St. Jude Medical Inc., St. Paul, MN). The coronary ostia were directly reimplanted into the composite graft, remnants of the aneurysm were wrapped around the graft, and a Cabrol decompression graft was performed to the right atrium. The mitral valve was replaced with a #31-mm St. Jude mechanical valve, and the coarctation was repaired with an ascending aorta-supraceliac aorto bypass graft using a #18mm Vascutek prosthesis (Terumo Gelsoft, Vascutek, Inchinnan, UK).The patient now returned with chest pain and dyspnea. A multislice computed tomography (CT) angiogram showed a large false aneurysm due to a leak resulting from the detachment of the right coronary ostial button (Figure 1).At the time of surgery cardiopulmonary bypass was instituted with an arterial cannula in the right subclavian artery and a venous cannula in the right femoral vein. Following a redo mediansternotomy the false aneurysm was purposefully entered, blood clots were removed, and the bleeding site of the detached right coronary button was identified.The aorta was then crossclamped and the heart arrested with cold blood cardioplegia directly administered through the right coronary ostium. The right coronary button was completely detached and the residual opening in the aortic conduit was closed with a polytetrafluoroethylene patch. The right coronary button was anastomosed in an end to end fashion to an 8-mm Gore-Tex graft (Gore Inc, Flagstaff, AZ) using a running 4-0 Gore-Tex suture (Figures 2A and 2B). This was then anastomosed end to side to the previously placed ascending aorto supraceliac aortic bypass graft using a 4-0 running Gore-Tex suture (Figures 2A and 2B). The crossclamp and bypass times were 154 and 54 min, respectively. The patient tolerated the procedure well and had an uncomplicated postoperative course. A postoperative CT angiogram showed a patent Gore-Tex interposition graft (Figure 2). ORCID Ivan Budimirhttp://orcid.org/0000-0002-0202-9208 FIGURE 1 Preoperative MSCT. Aortic root false aneurysm (yellow arrow). MSCT, multislice computed tomography J Card Surg. 2017;32:595-596. wileyonlinelibrary.com/journal/jocs

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Implantacija valvularne proteze jedan je od najËeπÊih kardiokirurπkih zahvata s viπe od 700 implantacija koje se obave u Hrvatskoj 1 i viπe od 90.000 godiπnje u Sjedinjenim AmeriËkim Draeavama 2 . UËestalost postoperativnih paravalvularnih regurgitacija varira izmeu 2% do 10% na aortnoj i 7% do 17% na mitralnoj poziciji [3][4][5] . Uzrok paravalvularne regurgitacije (PVL) obiËno je dehiscencija sutura nastala zbog infekcije, preosjetljivosti tkiva ili anularnih kalcifikacija. VeÊina PVL nije znaËajna i ostaje kliniËki neupadljiva, no kod 1% do 3% Êe postati simptomatska i zahtijevati reoperaciju 6 . Bolesnici s kliniËki znaËajnom PVL mogu pokazivati simptome i znakove kongestivnog zatajivanja srca, kao i hemolitiËke anemije. Reoperacija predstavlja tradicionalni naËin lijeËenja ovih bolesnika, no povezana je sa znaËajnim rizicima i stoga se ponekad ne uzima kao moguÊa opcija 7,8 . Takoer i ponovni kirurπki zahvat ne mora biti uspjeπan, jer Êe prvobitni anatomski problem i dalje biti prisutan. Stoga su razvijeni