Outcomes Following Pediatric Coronary Artery Bypass Grafting with Microsurgery
Mark Shafarenko, BSc1, Joseph Catapano, MD PhD2, Shuhua Luo, MD PhD3, Ronald M. Zuker, MD4, Glen Van Arsdell, MD3, Gregory H. Borschel, MD4.
1University of Toronto, Faculty of Medicine, Toronto, ON, Canada, 2Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, Canada, 3Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada, 4Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
Pediatric coronary artery bypass grafting (PCABG) is performed for critical coronary stenosis. PCABG presents unique surgical challenges for surgeons including the small vessel caliber, small areas of vascular access, and the position and distribution of the coronary vasculature. Serious perioperative complications are common, including arrhythmias, myocardial infarction, and sudden death. To reduce technical complications and improve outcomes, the divisions of Cardiothoracic Surgery and Plastic and Reconstructive Surgery at our centre have collaborated during these procedures, to utilize the expertise of the plastic surgeon in performing microvascular anastomosis. We provide a detailed technical description and report our institutional experience for all patients who have undergone PCABG procedures, separately analyzing how these outcomes compare to patients in which microvascular techniques were used.
The records of all patients who underwent PCABG procedures (either as primary or secondary procedures) from 2000-2017 were retrospectively reviewed. Variables assessed included basic demographic data, diagnosis, pre-operative echocardiography and angiography, details of PCABG and any associated procedures, perioperative complications, graft patency, and clinical and functional outcomes. Left ventricular ejection fraction was compared pre-and post-operatively using a Student's t test
Outcomes were evaluated for a total of 24 patients. The median age was 8.39 years (range, 0.27-16.21 years) and the median weight was 24.2 kg (range, 4.6-71 kg) at operation. Three male and three female patients had microsurgical involvement, comprising the six youngest patients in the cohort, with a median age at operation of 2.01 years (range, 0.27-4.43 years) and a median weight at operation was 10.75 kg (range, 4.6-12.2 kg). Three major anastomotic complications occurred requiring reoperation, although none occurred in the microvascular group. Median follow up was 3.54 years (range, 0.1-12 years) and 5.25 years (range, 1.92-12) for the entire cohort and the microvascular group, respectively. Three patients were symptomatic according to subjective report at last follow-up and two deaths occurred in our series, all in the group without microsurgical involvement. All grafts were patent in both groups. Differences between pre-and post-operative ejection fraction were not statistically different between patients with and without microsurgical involvement.
Our results demonstrate the positive impact of collaboration between cardiac and microvascular surgeons during PCABG procedures, and the subsequent reduction in complications that can be expected. This highlights the broad utility of microsurgical expertise and how these techniques may be used to improve patient outcomes. Larger studies in the future with age-matched controls are required to determine whether microsurgical involvement in PCABG improves outcomes.
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