Coronary artery bypass graft

Coronary artery bypass grafting (CABG) is the standard treatment for advanced coronary artery diseases (CAD). Optimal placement of the bypass graft on the diseased vessel is very important. To assist the surgeon in this matter, a computer assistance system has been developed facilitating navigation on the heart surface. After retrospective validation on patient data sets yielded good results, the system was successfully applied for in-vivo navigation on the front side of the heart during several CABG procedures. Postoperative evaluation confirmed that intraoperative navigation has been performed with adequate accuracy.

Computer-assistance in coronary artery bypass grafting at the open heart with intraoperative navigation enables accurate placement of a bypass graft to a preoperatively planned anastomosis site. So far, navigation information were displayed on a monitor, requiring the operating surgeon to change focus from the monitor to the surgical site and vice versa during the navigation process. In this work, a mechanism is presented which is intended to enable the projection of registered preprocedural information directly onto the surface of the open heart. The method was tested on a heart phantom yielding good results.

seal is maintained by gentle pressure on the TT keeping the cuff pressing on the vocal cords. During percutaneous tracheostomy the bougie remains in the trachea. When ventilation through the tracheostomy tube (cuff inflated) is confirmed, the TT and bougie are withdrawn. Throughout the procedure, if ventilation difficulties occur, the TT can be easily re-inserted using the bougie as a guide. Results Three different bougies were used: types (number used) were Eschmann (29), size 10 Portex disposable (four) and size 12 Portex disposable (13). Three patients were trauma cases: a neutral cervical position was maintained. In 33 cases the Blue Rhino dilator and in 12 cases the Ultra-Perc (White Rhino) dilator was used. One case was a serial dilator (see later). The bougie for airway control for percutaneous tracheostomy was associated with zero hypoxic episodes in 46 cases. Minor bougie damage in two cases caused no problems. Other complications seen were either minor or unlikely to be due to the bougie.

Background Adaptive support ventilation (ASV) is a microprocessor-controlled mode of mechanical ventilation that maintains a predefined minute ventilation with an optimal breathing pattern (tidal volume and rate) by automatically adapting inspiratory pressure and ventilator rate to changes in the patient's condition. The aim of the current study was to test the hypothesis that a protocol of respiratory weaning based on ASV could reduce the duration of tracheal intubation after uncomplicated cardiac surgery ("fast-track" surgery). Methods A group of patients being given ASV (group ASV) was compared with a control group (group control) in a randomized controlled study. After coronary artery bypass grafting during general anesthesia with midazolam and fentanyl, patients were randomly assigned to group ASV or group control. Both protocols were divided into three predefined phases, and weaning progressed according to arterial blood gas and clinical criteria. In phase 1, ASV...

Adiponectin functions as an anti-inflammatory and antiatherogenic factor, and the decreased plasma adiponectin is a risk factor for coronary disease. The aim of this study was to determine the changes in plasma levels of adiponectin, a potential parameter for atherosclerosis, in patients underwent surgical revascularization. We included forty patients with atherosclerosis (age, 58 ± 9 years; body mass index [BMI] 26.93 ± 2.3 kg/m 2 ) undergoing coronary artery bypass grafting (CABG). Control group consisted of 40 healthy volunteers, matched for age, gender and BMI (age, 56 ± 6 years; BMI, 26.78 ± 2.3 kg/m 2 ). We measured various parameters, including high sensitive Creactive protein (hsCRP), homeostasis model assessment-insulin resistance (HOMA-IR) indexes, and adiponectin. The baseline profile of the patients before CABG showed higher levels of serum hsCRP (13.15 ± 2.40 mg/l vs 3.97 ± 1.07 mg/l) and HOMA-IR (1.86 ± 0.30 vs 1.26 ± 0.33) and lower plasma adiponectin levels (7.02 ± 2.01 μ g/ml vs 25.46 ± 3.9 μ g/ml), compared to controls ( p < 0.001 for each parameter). Plasma adiponectin level was increased one month after CABG from the baseline level to 8.67 ± 2.05 μ g/ml ( p < 0.001), although the level was still lower than the control value. Thus, postoperative adiponectin level might be helpful for evaluating the progression of atherosclerosis. Moreover, CABG significantly decreased hsCRP to 7.25 ± 1.89 mg/l and HOMA-IR to 1.59 ± 0.33, although these levels were higher than the controls. These results suggest that CABG decreases the cardiac risk factors in atherosclerotic patients.

Objective: Through a retrospective study on the use of fresh homografts in 655 aortic valve replacement patients over a period of 23 years, we aimed to assess the reasons for eventual reoperation and causes of valve dysfunction. Methods: Between January 1980 and December 2002, 655 patients received fresh homografts. All homografts were antibiotic sterilized and stored at 4 8C. During this time, 139 patients (116 male and 23 female) with a mean age of 46.7 years (range 18 -72) required reoperation. Results: The 30-day hospital overall mortality was 2.87%. The mean durability for all homografts was 12.4 ^4.54 years (1 month to 23 years). The cumulative rates for freedom from reoperation for any cause were 94.09 ^2% at 5 years and 87.9% ^4% at 10 years, 76.6 at 15 years, 49.55 at 20 years. The major cause of valve dysfunction and indication for reoperation was degeneration in 111 patients (79.8%). Predominant aortic valve insufficiency in 87 patients (62.5%) and predominant stenosis in 24 patients (17.26%). Endocarditis occurred in 21 patients (15.1%). Early endocarditis was diagnosed in five patients (3.59%), late endocarditis in 16 patients (11.5%). Additional causes for reoperation included ascending aortic aneurysm, mitral valve insufficiency and congestive cardiomyopathy. Seventeen patients (12.2%) required concomitant procedures. Coronary artery bypass grafting was performed in six cases (4.3%), mitral valve replacement in five cases (3.59%), mitral valve annuloplasty in six (4.3%). The primary reoperative procedure was artificial/mechanical aortic valve implantation. In five cases, St. Jude Medical conduit grafts were implanted due to ascending aortic aneurysms. Homograft reimplantation was performed in four cases. One patient underwent mitral valve replacement and one patient received a heart transplant. Conclusion: The results of the study suggest that reoperation in patients with aortic homografts is a low-risk procedure as compared to alternative therapies. Primary allograft aortic valve replacement can give acceptable results for up to 23 years. The major cause of valve dysfunction and indication for reoperation was degeneration. Cumulative rates for freedom from reoperation for any cause in age groups suggest careful selection and indications in homograft implantation in the younger patients. Young age is a risk factor for an early homograft structural deterioration (degeneration).

Background: Randomized clinical trials showed the benefit of pharmacological and revascularization treatments in secondary prevention of myocardial infarction (MI), in selected population with highly controlled interventions. The objective of this study is to measure these treatments' impact on the cardiovascular (CV) mortality rate among patients receiving usual care in the province of Quebec. The study population consisted of a "naturalistic" cohort of all patients ≥ 65 years old living in the Quebec province, who survived a MI (ICD-9: 410) in 1998. The studied dependant variable was time to death from a CV disease. Independent variables were revascularization procedure and cardioprotective drugs. Death from a non CV disease was also studied for comparison. Revascularization procedure was defined as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). The exposure to cardioprotective drugs was defined as the number of cardioprotective drug classes (Acetylsalicylic Acid (ASA), Beta-Blockers, Angiotensin-Converting Enzyme (ACE) Inhibitors, Statins) claimed within the index period (first 30 days after the index hospitalization). Age, gender and a comorbidity index were used as covariates. Kaplan-Meier survival curves, Cox proportional hazard models, logistic regressions and regression trees were used. The study population totaled 5596 patients (3206 men; 2390 women). We observed 1128 deaths (20%) within two years following index hospitalization, of them 603 from CV disease. The CV survival rate at two years is much greater for patients with revascularization, regardless of pharmacological treatments. For patients without revascularization, the CV survival rate increases with the number of cardioprotective drug classes claimed. Finally, Cox proportional hazard models, regression tree and logistic regression analyses all revealed that the absence of revascularization and, to a lower extent, absence of cardioprotective drugs were major predictors for CV death, even after adjusting for age, gender and comorbidity. Considering usual care management of MI in the province of Quebec in 1998, CV survival is positively correlated to the presence of a revascularization procedure and to the intensity of cardioprotective pharmacological treatment. These results are coherent with data from randomized control trials.

Objectives: The effectiveness of a concomitant anti-arrhythmic surgical procedure in coronary artery bypass grafting (CABG) patients with permanent atrial fibrillation (AF) was evaluated. Methods: This prospective study included 36 CABG patients, who had a concomitant anti-arrhythmic procedure using irrigated cooled-tip radiofrequency ablation. Follow-up included a 24 h EKG and ultrasound examination at 3, 6, 12 months. Results: Mean (SD) age was 68.7 years (8.0), left atrial diameter 44.9 mm (6.7), preoperative duration of AF 67 months (73), left ventricular ejection fraction 54% (14), euroscore 5.5 (2.6), number of distal anastomoses 3.3 (1.2), aortic cross-clamp time 90 (19) min, extracorporeal bypass time 156 (38) min. Thirty-day mortality was 2.8% (1/36). Mean (SD) follow-up was 25.3 months (17.9). Cumulative survival rates (SE) at 12 and 24 months were 0.94 (0.04) and 0.90 (0.06). Cumulative postoperative sinus rhythm (SR) rates (SE) at 6 and 12 months were 0.60 (0.08) and 0.75 (0.08). Restored bi-atrial contraction occurred in 73% (19/26) of all SR patients. As a consequence coumadine was stopped, after the 6th postoperative month, in 76% (16/21) in this subset of patients, corresponding with 44% (16/36) of all study group patients. One patient experienced a sick sinus syndrome 12 months postoperatively, for which a DDD pacemaker was implanted. Three out of five patients with a preexistent VVI pacemaker regained a stable postoperative SR with bi-atrial contraction, obviating the need of any pacemaker support.

Background: Knowledge of predictors for health related quality of life (HRQoL) after coronary artery bypass grafting is limited. Aim: To identify preoperative and postoperative factors related to physical and mental health status 6 months after surgery. Methods: 185 patients completed the Short Form-36 survey preoperatively and 6 months after surgery. Multiple linear regression was used to identify significant independent predictors for both physical and mental health component summary scores 6 months after surgery. Results: Significant predictors for physical health were preoperative physical status (PCS), marital status, hospitalised with acute myocardial infarction and serum creatine kinase-MB (CK-MB) 1st postoperative day. Preoperative mental status (MCS and anxiety and/or depression symptoms) and postoperative pleural drainage were significant predictors of mental health 6 months after surgery. Conclusion: This study identified predictors that have an impact on CABG patients' HRQoL 6 months after surgery. These predictors could cause elevated risk for morbidity and mortality. Clinicians have the opportunity to improve the HRQoL of CABG patients by targeting counselling and/or interventions focusing on the identified predictors.

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Nicorandil is a K ATP channel opener used to treat angina. It is cardioprotective and a vasodilator. We conducted a prospective, randomized, double-blind, placebo-controlled study to assess oral nicorandil in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Twenty-two patients received nicorandil (10 mg twice a day) and 23 patients received placebo. Haemodynamic data were recorded before induction of anaesthesia (T0), 5 and 20 min after starting mechanical ventilation (T1, T2), before aortic cannulation (T3), after 30 min of CPB (T4), 10 min after CPB (T5) and after 3, 8 and 18 h in the intensive care unit (T6, T7, T8). Serum proteins (creatine kinase metabolite and cardiac troponin I) were measured before and 8 and 18 h after surgery. Haemodynamic values did not differ between the two groups. There was no tachycardia during the study, no signi®cant difference in hypotensive episodes, ST segment changes and no changes in cardiac enzymes. Myocardial infarction after surgery was similar in the two groups. Vasoactive therapy was similar in the two groups. Nicorandil can be continued safely up to premedication without deleterious haemodynamic consequences, but a myocardial protective effect of nicorandil in CABG surgery was not found.

The purpose of the study was to determine the period prevalence of acute renal failure (ARF) after coronary bypass surgery (CABG) at the University Hospital of the West Iindies and to identify risk factors. Method: A retrospective analysis of patients who underwent CABG during the period 1994-2004 was done. Data collected included; age, gender, weight, the presence of hypertension (HTN), diabetes mellitus (DM), hypercholesterolaemia, previous myocardial infarction (MI), blood pressure on admission, urea and creatinine one year prior to surgery, on admission for surgery and post-surgery, duration of intra-operative hypotension, duration of cardiopulmonary bypass, perfusion pressure and the perioperative medications. Results: The case notes of 62 patients (68.9%) were obtained for analysis. There were 47 (75.8%) males and 15 females (24.2%) -a 3:1 ratio. The prevalence of HTN and DM in the study sample was 78% and 72% respectively, hypercholesterolaemia was 31% and a previous MI was 29%. There were no differences based on gender. Post CABG complications were: persistent postoperative hypotension (6.8%), congestive cardiac failure (CCF) (6.8%), arrhythmia (6.8%), sepsis (6.8%), lower respiratory tract infection (LRTI) and pleural effusion (5.1%), heart block (3.4%), pulmonary embolism (1.7%), cellulitis and haematoma formation were 1.7% . Three patients had increases in postoperative creatinine values > 89 µmol/L over the postoperative value resulting in a prevalence of ARF of 5%. One of the three patients died and none received dialysis. There were no statistical difference in pre-operative clinical and biochemical characteristics based on the presence or absence of ARF. The presence of diabetes and increased length of stay were significant predictors of increasing postoperative creatinine values adjusting for pre-operative creatinine values. In addition, the presence of diabetes mellitus and male gender were significant predictors of increasing postoperative urea values. Conclusion: DM is a significant risk factor for the development of ARF post CABG.

Objectives: To describe morbidity and mortality in patients waiting for coronary artery bypass graft (CABG) surgery and to assess determinants for the occurrence of these complications. Methods: A prospective cohort study was carried out in a tertiary referral general teaching hospital. Three hundred and sixty consecutive patients with a priority of routine or urgent who were accepted for CABG or CABG with additional valve surgery were evaluated. Follow-up began from the moment of acceptance until the procedure took place for cardiac death, myocardial infarction and unstable angina requiring hospital admission. Results: The median (25±75th percentile) waiting time in the two priority groups was 100 (79±119) days for the routine group and 69 (38±91) days for the urgent group. Overall, eight patients died, seven suffered a myocardial infarction, and 33 episodes of unstable angina requiring immediate hospitalization occurred. The majority of events took place during the ®rst 30 days on the waiting list. Unstable angina less than 3 months before acceptance was identi®ed as an independent predictor (hazard ratio 2.5, 95% con®dence interval 1.2±5.1) for complications during the wait. The prognostic value of smoking and familial cardiovascular disease was found to vary depending on the priority assigned to the patient. Conclusions: Complications occur relatively early during the time on the waiting list. If complications in coronary heart disease cannot be predicted more accurately, the only way to diminish the complication rate is drastic reduction of waiting times.

Objective: To assess the determinants of poor mid-term health related quality of life (HRQoL) at one year after primary isolated coronary artery bypass grafting (CABG). Methods: 463 patients who underwent primary isolated CABG for multivessel disease and came for their annual follow up at the outpatient clinic during one year at Harefield Hospital, Middlesex, were approached to participate in the present study. Prospective clinical data were collected as part of the clinical care of the patients and were retrospectively analysed when the patients consented to participate in the study at their outpatient visit. After their consent they were given three HRQoL assessment questionnaires. Scores, together with clinical data, were analysed by both univariate and multivariate analyses with regard to poor HRQoL outcome. Results: 437 (94.4%) patients consented to participate in the study and filled in the HRQoL questionnaires. Ten variables were identified in the univariate analysis as potential predictors of poor scores of the physical element of HRQoL; however, only three variables-gastrointestinal problems, congestive heart failure, and type D personality trait-predicted poor physical scores independently. Eleven variables were identified in the univariate analysis as potential predictors of poor scores of the mental element of HRQoL; however, only three variables-peripheral vascular disease, infective complications, and type D personality trait-predicted poor physical scores independently. Conclusion: Preoperative gastrointestinal problems, preoperative congestive heart failure, and type D personality trait were independent predictors of the poor physical component of HRQoL. Peripheral vascular disease, infective complications, and type D personality trait were independent predictors of the poor mental component of HRQoL. Interestingly, patients with type D personality were more than twice as likely to have poor physical HRQoL and more than five times as likely to have poor mental HRQoL.

Objective: Techniques aimed at improving the performance of arterial conduits will maximize the clinical benefit achievable with coronary artery bypass surgery. Controlling oxidant stress could be a strategy for preventing early graft deterioration. We tested the effect of a free radical scavenger, ascorbic acid (vitamin C), on preserving the endothelium-dependent vasodilatation function in vitro of radial artery and internal thoracic artery. We also tested its effect on the amount of reactive oxygen species (ROS) generated by each graft. Methods: Radial artery (RA, n ¼ 25) and internal thoracic (ITA, n ¼ 19) segments were obtained from coronary artery bypass grafting patients. Each segment was divided into 3 -4 mm vascular rings and incubated with or without ascorbic acid (10 23 mol/l) for 1 h or 72 h. Using the organ bath technique, the endothelium-dependent vasodilatation function was tested in vitro by the addition of cumulative concentrations of acetylcholine (10 29 -10 25 mol/l) following vasocontraction by endothelin-1 (3 £ 10 28 mol/l). ROS were measured by using chemiluminescence technique at 1-h and after 72 h incubation with or without ascorbic acid. Results: There were no differences in the vasodilatation function between control and ascorbic acid group of both arteries in the 1-hour incubation experiment. However, in the 72 h incubation experiment, ascorbic acid preserved the endothelium-dependent vasodilatation function of RA compared with control group (35.8 ^2.2% vs. 25.9 ^2.1%; P ¼ 0:005), but not ITA (39 ^3.5% vs. 40.5 ^9.3%; P ¼ 0:438). After 72 h incubation, RA generated significantly more free radicals compared with 1 h (133.7 ^151.5 vs. 16.8 ^16.8 cps=mg £ 100; P ¼ 0:01); however, AA has no statistically significant effect on decreasing the amount of free radicals generated by both arteries. Conclusions: In RA, ascorbic acid is able to preserve the endothelium-dependent vasodilatation function after 72 h incubation, but not after 1 h. However, the mechanism of action of AA is not completely understood. This finding could open the door for understanding the role of oxidant stress and antioxidants in preserving the endothelial function of coronary artery bypass grafts.

Background: Preoperative anxiety and physical unfitness have been shown to have adverse effects on recovery from cardiac surgery. This study involving cardiac surgery patients was primarily aimed at assessing the feasibility of delivering physical conditioning and stress reduction programs within the public hospital setting. Secondary aims were to evaluate the effect of these programs on quality of life (QOL), rates of postoperative atrial fibrillation (AF) and length of stay (LOS) in hospital. Methods: Elective patients scheduled for coronary artery bypass graft and/or valve surgery at a public hospital in Melbourne, Australia were enrolled. Patients were randomized to receive either holistic therapy (HT) or usual care (UC). HT consisted of a series of light physical exercise sessions together with a mental stress reduction program administered in an outpatient setting for the first two weeks after placement on the waiting list for surgery. A selfadministered SF-36 questionnaire was used to measure QOL and hospital records to collect data on LOS and rate of postoperative AF. Results: The study population comprised 117 patients of whom 60 received HT and 57 received UC. Both programs were able to be delivered within the hospital setting but ongoing therapy beyond the two week duration of the program was not carried out due to long waiting periods and insufficient resources. HT, as delivered in this study, compared to UC did not result in significant changes in QOL, LOS or AF incidence. Conclusions: Preoperative holistic therapy can be delivered in the hospital setting, although two weeks is insufficient to provide benefits beyond usual care on QOL, LOS or postoperative AF. Further research is now required to determine whether a similar program of longer duration, or targeted to high risk patients can provide measurable benefits. Trial registration: This trial was conducted as part of a larger study and according to the principles contained in the CONSORT statement 2001.

Objective: To identify independent factors associated with early (30-day) mortality and in surviving patients, identify factors for late (1-year) mortality following primary coronary artery bypass graft (CABG) surgery and to test the interaction with age. Methods: An analysis of a single centre's data contribution to the Society for Cardiothoracic Surgery in Great Britain and Ireland database was performed. Data on consecutive patients aged !75 years (n = 659) and aged 60-74 years (n = 3024) undergoing primary CABG surgery (1999)(2000)(2001)(2002)(2003)(2004)(2005) were analysed. One-year mortality data were collected using the Office of National Statistics (ONS) tracking system. Factors associated with early and late mortality were identified using Cox regression; hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. Results: The proportion of patients aged !75 years increased by 10% over 5 years (2000)(2001)(2002)(2003)(2004)(2005). One-year mortality in the elderly showed a significant linear decrease from 15% to 7% ( p = 0.01) while mortality in the younger cohort remained static at 2-4%. Early mortality in the elderly group was 5% compared to 1.8% in the younger group ( p < 0.001), while late mortality was 4.1% vs 1.8%, respectively ( p < 0.001). Factors independently associated with early mortality were age !75 years, HR 2.0 (95% CI 1.28, 3.11); female gender; angina (CSS III-IV); and cardiopulmonary bypass duration >97 minutes. Arrhythmia and renal impairment were risk factors common in both early and late mortality models. Risk factors for late mortality also included ventricular ejection fraction < 30%, non-elective surgery and arteriopathy. Age was not an independent risk factor for late mortality. Conclusion: Mortality in elderly patients showed a substantial improvement, but remained over twice that of younger patients. The difference in factors associated with early and 1-year morality suggests the need for effective short-and long-term strategies, particularly in the management of chronic diseases such as heart and renal failure.

The comparators were justified on the grounds that CABG represented existing practice. The consideration of MT was justified because existing practice may not be cost-effective by itself, and the interpretation of the results of comparisons between PET and CABG may be misleading.

Background/Purpose: Despite general recommendation of short-course antibiotic prophylaxis, prolonged antibiotic use is still commonly reported in clinical settings. This study compared the efficacy of 1-day versus 3-day antibiotic prophylaxis in preventing surgical site infection (SSI) in patients undergoing coronary artery bypass graft (CABG). Methods: This prospective, randomized control study was performed in a tertiary-care medical center from June 2002 to April 2004. Patients underwent non-emergency CABG and were randomized into two groups receiving either 1 day or 3 days cefazolin prophylaxis. The SSI rates were compared between the two groups. Results: During the study period, 231 patients were enrolled, 120 in the 1-day group and 111 in the 3-day group. Twenty-two episodes of SSI were observed within 1 month after operation: 13 (10.8%) in the 1-day group and nine (8.1%) in the 3-day group (odds ratio: 1.37; 95% confidence interval: 0.56e3.33; p Z 0.48). By logistic regression analysis, 1-day prophylaxis with cefazolin was not associated with higher risk of SSI (adjusted odds ratio: 0.91; 95% confidence interval: 0.32e2.56; p Z 0.85).

Seguimento a longo prazo de pacientes submetidos à revascularização do miocárdio com uso exclusivo de enxertos arteriais Resumo Objetivo: Avaliar os resultados a longo prazo da cirurgia de revascularização do miocárdio com o uso exclusivo de enxertos arteriais em pacientes com doença coronariana triarterial. Métodos: Avaliamos 136 pacientes submetidos a cirurgia de revascularização do miocárdio isolada, no período janeiro de 1995 e dezembro de 1997. Utilizaram-se 353 enxertos para revascularizar 449 artérias (média: 3,30 por paciente). Foram utilizadas a artéria torácica interna esquerda (99,2%), artéria torácica interna direita (56,6%), artéria radial (87,5%), artéria gastroepiplóica direita (20,5%) e uma artéria epigástrica inferior. Setenta e seis (55,8%) pacientes receberam enxertos compostos (em "Y") e 66 (48,5%) receberam anastomoses seqüenciais. Resultados: A mortalidade hospitalar foi de 4,4%. No seguimento a longo prazo, (9,5 a 12,8 anos), 82,1% dos pacientes não apresentaram nenhum evento cardíaco. Vinte (17,9%) pacientes necessitaram de reinternação por eventos cardiovasculares; 15 com angina e cinco com infarto agudo do miocárdio, sendo que três apresentaram insuficiência cardíaca associada. Oito (7,1%) pacientes necessitaram de reintervenção por doença coronariana, sendo um reoperado e os demais submetidos a angioplastia com stent. A probabilidade estimada livre de eventos cardíacos foi de 98,2%, 95,4% e 84,2% em 1, 5 e 10 anos, respectivamente. Ocorreram 16 (14,2%) óbitos tardios, sendo quatro deles (3,6%) de causa cardíaca. Sobrevida actuarial em 12,8 anos por todas as causas foi de 85% neste grupo. Conclusão: Revascularização do miocárdio com o uso exclusivo de enxertos arteriais em pacientes com doença coronariana triarterial é um procedimento seguro, com bons resultados a longo prazo. Descritores: Revascularização miocárdica. Arteriosclerose/ cirurgia. Artéria torácica interna. Artéria radial.

With improvements in anesthetic, operative, and postoperative care, the elective repair of abdominal aortic aneurysms (AAAs) has become a highly effective procedure, with most series reporting mortality rates of less than 5%. However, a similar evolution has not occurred for the emergency repair of ruptured AAAs. Despite advances in care that have occurred over the last few decades, the mortality rate for the emergency repair of ruptured AAAs still remains high at 20% to 70%. Such dismal results have prompted many to question whether repairing ruptured AAAs should even be attempted, particularly in subsets of patients in whom the probability of a fatal outcome is high. Prolonged suffering and pain may precede eventual death. Moreover, the average cost of repairing ruptured aneurysms is significantly higher than that of elective repair because of the greater use of valuable resources. The risks associated with repairing ruptured AAAs have been assessed in multiple studies. In only a few reports has the cost of the repair been evaluated, and in these studies, only the costs associated with the initial hospitalization were determined. A formal cost-effectiveness analysis has not been performed in which the long-term

Objective: Recently published data from the North American Carotid Endarterectomy Trial revealed a benefit for carotid endarterectomy (CEA) in symptomatic patients with moderate (50% to 69%) carotid stenosis. This benefit was significant but small (absolute stroke risk reduction at 5 years, 6.5%; 22.2% vs 15.7%), and thus, the authors of this study were tentative in the recommendation of operation for these patients. To better elucidate whether CEA in symptomatic patients with moderate carotid stenosis is a proper allocation of societal resources, we examined the cost-effectiveness of this intervention. Methods: A decision-analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment for a hypothetical cohort of 66-yearold patients with moderate carotid stenosis. This model allowed the comparison of not only the immediate hospitalization but also the lifetime costs and benefits of these two strategies. Our measure of outcome was the cost-effectiveness ratio (CER), defined as the incremental lifetime cost per quality-adjusted life year saved. We assumed an operative stroke and death rate of 6.6% and a declining risk of ipsilateral stroke after the ischemic event with medical treatment (first year, 9.3%; second year, 4%; subsequent years, 3%). The hospitalization cost of CEA ($6420) and the annual costs of major stroke ($26,880), minor stroke ($798), and aspirin therapy ($63) were estimated from a hospital cost accounting system and the literature. Results: CEA for moderate carotid stenosis increased the survival rate by 0.13 qualityadjusted life years as compared with medical treatment at an additional lifetime cost of $580. Thus, CEA was cost-effective with a CER of $4462. Society is usually willing to pay for interventions with CERs of less than $60,000 (eg, CERs for coronary artery bypass grafting at $9100 and for dialysis at $53,000). CEA was not cost-effective if the perioperative risk was greater than 11.3%, if the ipsilateral stroke rate associated with medical treatment at 1 year was reduced to 4.3%, if the age of the patient exceeded 83 years, or if the cost of CEA exceeded $13,200. Conclusion: CEA in patients with symptomatic moderate carotid stenosis of 50% to 69% is cost-effective. Perioperative risk of stroke or death, medical and surgical stroke risk, cost of CEA, and age are important determinants of the cost-effectiveness of this intervention. (

Objective: The efficacy of percutaneous and surgical revascularization in acute coronary syndromes without ST-segment elevation is similar. Therefore, other factors, like health-related quality of life, should play an important role in choosing the revascularization method. Methods: We compared 12-month health-related quality of life for high-risk patients with acute coronary syndromes without ST-segment elevation assigned to percutaneous coronary intervention (group A) versus coronary artery bypass graft surgery (group B). Patients had an episode of rest angina within 24 h prior to admission and had to fulfil at least one of the criteria: (1) ST-segment depression (R0.05 mV), ( ) transient (!20 min) ST-segment elevation or T-wave inversion (R0.1 mV), (3) positive serum cardiac markers. Four hundred and ninety-six (91.34%) of 543 patients alive 12-months after index hospitalization completed a Short Form-36 (SF-36) health status survey. Group A comprised 392 patients and group B comprised 104 patients. We compared mental component summary (MCS) and physical component summary (PCS) scores from the SF-36 survey between analyzed groups. Results: There were no significant differences in MCS scores (47.21G12.30 vs. 46.60G 11.3 in group A and group B, respectively, NS). PCS scores were lower in group A (38.30G11.10 vs. 42.64G9.76; pZ0.003). Patients of group A had a higher rate of unstable angina (22.45 vs. 5.77%, pZ0.0002) and repeated revascularization (12.76 vs. 1.92%, pZ0.001) at 1 year. Patients of group A also had higher systolic and diastolic blood pressure during follow-up (138.17G20.41 vs. 133.47G19.21, pZ0.04 and 82.48G11.32 vs. 77.25G16.17, pZ0.0003, respectively). Systolic blood pressure was inversely associated with PCS scores in group A (Spearman's RZ K0.18 pZ0.0007). Conclusions: This study has shown that there is a significant difference in health-related quality of life 12-months after percutaneous coronary intervention and coronary artery bypass graft surgery. This difference arises from better physical function (physical component summary) for coronary artery bypass graft surgery patients compared with percutaneous coronary intervention patients. Despite impairment of the physical health status (physical component summary), the mental health status (mental component summary) remained similar in both groups.

The aim of the study was to develop methodology for long-term study of ECG parameters, in particular the P wave parameters. In this study we address continuous monitoring of different P wave parameters in the group of patients after Coronary Artery Bypass Grafting (CABG) in order to examine potential predictors of atrial fibrillation. Lead II of the standard surface ECG was recorded in the period of typically 48 hours in patients after CABG. Dyadic wavelet transform analysis with first derivation of Gaussian smoothing function as a mother wavelet, was used for a QRS and a P wave detection, characterization and delineation. During the recording, for every patient, in every hour, vector of 108 P wave components was calculated, allowing continuous and deeper insight into atrial activity.

Aortic valve replacement is an established therapy for aortic valve disease, but survival is strongly related to the presence of coronary artery disease. In the past decade several less-invasive techniques have emerged in aortic valve surgery. These approaches are associated with reduced sternotomyrelated morbidity, but some may cause injury to one or both internal thoracic arteries (ITAs). The latter could be detrimental to the patient who needs coronary artery bypass grafting (CABG) at an older age, since the ITAs no longer can be used. However, little is known about the need for CABG after primary isolated aortic valve surgery. The goal of the present study was to assess the need for CABG after primary isolated aortic valve surgery and to identify possible predictors of future CABG at the time of the primary operation. Methods. We analyzed data of 1598 patients who had primary isolated aortic valve surgery between 1962 and 1997, excluding those with previous cardiac operations or concomitant procedures during the aortic valve operation that required a median sternotomy. The patient data from 2 centers, the

Objectives: Ventricular septal rupture is a rare but feared complication after acute myocardial infarction. Most reports about outcome after surgical treatment are single center experiences. We investigated the results after surgical repair in all patients in Sweden during a 7-year period. Methods: All patients undergoing surgical repair 1992-1998 were identified with the aid of the Swedish Heart Surgery Registry. The patients (nZ189, 63% men, mean age 69G8 years) were operated at 10 different centers. Pre-and peri-operative variables were collected from the Registry and individual patient charts. Mortality was calculated and a Cox proportional hazards regression model was used to identify independent predictors for early and late mortality. Mean follow-up was 2.4 years. Results: Seventy-seven of the 189 patients died within 30 days (41%). Urgent repair (Risk Ratio 4.2 (2.0-8.9), P!0.001) and posterior rupture (RR 2.1 (1.3-3.4), PZ0.002) were independent predictors of 30-day mortality. Total cumulative survival (Kaplan-Meyer) was 38% at 5 years. For patients that survived the first 30 days (nZ112), 5 year cumulative survival was 67%. Independent predictors for mortality after 30 days were number of concomitant coronary anastomoses (RR 1.5 (1.2-2.0), PZ0.001), residual postoperative shunt (RR 2.7 (1.4-5.4), PZ0.004) and postoperative dialysis (RR 3.4 (1.5-7.5), PZ0.003). Conclusions: Early mortality after surgical repair of post infarction septal rupture is still considerable. Early repair and posterior rupture are predictors of early mortality. Long-term survival in patients surviving the immediate postoperative period is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.

Off-pump totally endoscopic coronary artery bypass grafting is a milestone for cardiac surgery, and still a technical challenge. Indeed, the fast and complex cardiac motion makes this operating method technically demanding. Therefore, several robotic systems have been designed to assist the surgeons by compensating for the cardiac motion and providing a virtually motionless operating area. In the proposed systems, the servoing schemes often take advantage of a prediction algorithm that supplies the controller with some future heart motion. This prediction enlarges the control-loop bandwidth, thus allowing a better motion compensation. Obviously, improving the prediction accuracy will lead to better motion-compensation results. Thus, a current challenge in computer-assisted cardiac surgery research is the design of efficient heart-motion-prediction algorithms. In this paper, a detailed survey of the main existing prediction approaches is given and a classification is provided. Then, a novel prediction technique based on amplitude modulation is proposed, and compared with other techniques using in vivo collected datasets. A final discussion summarizes the main features of all the proposed approaches.

Introduction: Coronary Artery Bypass Graft (CABG) surgery is one of the main treatment methods for coronary artery disease. The change in hemodynamic indices after CABG surgery is a common but serious complication. Objective: This study aimed to determine the effect of aromatherapy using lavender essential oil on the hemodynamic indices of patients after undergoing CABG surgery. This randomized, double-blind, placebo-controlled clinical trial included 98 patients who were assigned into an experimental or a placebo group 3 days after undergoing CABG surgery. The experimental group inhaled five drops of lavender essential oil, whereas the placebo group inhaled five drops of distilled water for 30 min. Before and after the intervention, hemodynamic indices (systolic blood pressure, diastolic blood pressure, pulse rate, and respiratory rate) of patients were measured and recorded. The intervention in both groups was performed every 24 h for three consecutive days. The data were analyzed using the chi-square test, independent t-test, Mann-Whitney U test, repeated measures ANOVA, and regression analysis. The results revealed significant differences between the two groups in terms of the mean systolic blood pressure after the second day of intervention and the mean diastolic blood pressure after the first day of intervention (P=0.046 and 0.029, respectively), with the blood pressure significantly lower in the treatment group than in the placebo group. Among the hemodynamic indices tested, only the blood pressure of the patients was reduced by aromatherapy with lavender essential oil after CABG surgery; therefore, it can be used as a simple, complementary, and low-cost therapeutic intervention after CABG surgery to stabilize a patient's blood pressure.

Radial artery coronary bypass has emerged as a critical advancement in coronary artery bypass grafting (CABG), offering superior patency and long-term outcomes compared to traditional saphenous vein grafts (SVGs). The radial artery, with its muscular architecture and adaptability to high-pressure systems, serves as a durable conduit that is second only to the left internal mammary artery (LIMA). This arterial graft exhibits a greater resistance to atherosclerosis and occlusion, especially when coupled with optimized harvesting techniques such as the "no-touch technique" and pedicle dissection. The reintroduction of the radial artery in CABG, fueled by improved pharmacological vasodilator protocols and enhanced surgical techniques, has significantly reduced complications like vasospasm and graft failure. Patient selection guided by preoperative assessments such as the modified Allen test, along with proper perioperative pharmacologic preparation and interprofessional collaboration, has further improved clinical outcomes. This review provides an in-depth exploration of radial artery coronary bypass, encompassing anatomy and physiology, patient selection, surgical preparation, technical execution, complication management, and postoperative care. Emphasis is placed on the interdisciplinary approach that underpins the procedure's success and ensures optimal patient outcomes. Ultimately, the radial artery graft stands as a cornerstone in the evolution of total arterial revascularization strategies in modern cardiothoracic surgery.

Perioperative ischaemia and infarction after CABG are associated with increased morbidity and mortality. Objecti7e: To study causes of perioperative ischaemia and infarction by acute re-angiography and to treat incomplete re-vascularization caused by graft failure or any other cause. Methods: Between 1990Between and 1995Between , 2003 patients underwent an isolated CABG operation. Myocardial ischaemia was suspected if one or more of the following criteria were present: New changes in the ST-segment in the ECG; a CKMB value greater than 80 U/L; new Q-waves in the ECG; recurrent episodes of, or sustained ventricular tachyarrhythmia; ventricular fibrillation; haemodynamic deterioration and left ventricular failure. Acute coronary angiography was performed in stable patients, while haemodynamically severely compromised patients were rushed to the operating room. Results: A total of 71 (3.5%) patients of all CABGs with suspected graft failure were identified and included in the study. Patients were grouped according to whether they had an acute re-angiography (n= 59; group 1) or an immediate re-operation (n=12; group 2) performed. In group 1, the acute re-angiography demonstrated graft failure/incomplete re-vascularization in 43 patients (73%). The angiographic findings were: Occluded vein graft(s) in 19 (32%); poor distal run-off to the grafted coronary artery in ten (17%); internal mammary artery stenosis in four (7%); internal mammary artery occlusion in three (5%); vein graft stenoses in three (5%); left mammary artery subclavian artery steal in two (3%); and the wrong coronary artery grafted in one (2%). Based on the angiography findings, 27 patients were re-operated and re-grafted. At the time of re-operation, 18 patients (67%) had evolving infarction documented by ECG or CKMB. Two patients (3%) experienced stroke in immediate relation to the re-angiography. The 30-day mortality was three (7%). In group 2, graft occlusions were found in 11 patients (92%). The 30-day mortality was six (50%). Conclusion: An acute re-angiography demonstrated graft failure or incomplete re-vascularization in the majority of patients with myocardial ischaemia early after CABG. Re-operation for re-re-vascularization was performed with low risk. Few patients with circulatory collapse could be saved by an immediate re-operation without preceding angiography.

Background: Intra-coronary stents have been extensively employed in percutaneous coronary revascularization. However, despite breakthroughs and developments associated to this new technology, novel complications and findings have emerged compelling the cardiac surgeon to cope with this new scenario. The presence of an intra-coronary foreign body (stent) might induce an inflammatory reaction carrying functional and structural repercussions of the coronary artery and surrounding cardiac muscle. Method: Patients, who had previously undergone stent implantation (6 to 18 months) and were submitted to coronary artery bypass surgery, had biopsies taken from the grafted coronary artery distal to the stent and from the adjacent muscle. The collected samples were processed and stained with hematoxylin-eosin and histologically studied. Results: The histology of the coronary artery distal to the stent revealed chronic inflammatory processes and an intimal acute inflammatory infiltrate, with polymorphonuclear leukocytes even at long term follow-up, 12 months after stent implantation, disclosing an ongoing inflammatory process. The myocardium adjacent to the stent implantation site exhibited a significant chronic inflammatory infiltrate and fibrosis compatible with myocarditis. The presence of an intra-coronary stent induces an acute and chronic inflammatory reaction, even over the long term, with involvement of the distal coronary artery and surrounding myocardium. Further studies are necessary to assess the inflammatory process extension and its consequences.

Objective: Antiplatelet therapy is a class I indication in perioperative care after coronary artery bypass grafting to prevent graft occlusion. We sought to determine whether continuation of aspirin until surgery day suppresses platelet activity in the early period after off-pump coronary artery bypass grafting (OPCAB). Material and methods: Forty-two patients at mean age of 62.5 (AE7.9) years were included. Average risk rate (EuroScore logistic) was 2.2 (AE1.7) %. In all patients collagen/epinephrine stimulated platelet plug formation (closure time, CT) (CEPI-CT, s) using a platelet function analyzer (PFA-100), troponin I (TnI), creatine kinase-MB (CK-MB), ST segment elevation were evaluated a day before surgery, 4 h after chest closure, 24 and 120 h after surgery. Results: Preoperative mean CEPI-CTwas 224.8 (AE79.7) s. In 13 (30%) patients aspirin resistance (CEPI-CT < 163 s.) was observed. In 4, 24 and 120 h time points CEPI-CTwas significantly reduced: 164.4 (AE79), 168.5 (AE83.3) and 167.5 (AE80.4), respectively ( p < 0,001). TnI and CK-MB (ng/ml) levels raised in respective time points: 4 h (0.26 range 4; 1.9 range 6), 24 h (0.2 range 6; 2.6 range 8), 120 h (0.04 range 2; 0.6 range 5). ST segment elevation (mV) changed in time: 4 h (0.7 range 3.5), 48 h (0.7 range 2.8) and 120 h after surgery (0.2 range 1.5). There were no significant correlations between CEPI-CTand TnI, CK-MB, STsegment elevation found. Conclusion: Aspirin therapy continued until surgery day does not protect against acute platelet activation in patients after OPCAB.

Background: Conduction disturbances are very common after coronary artery bypass grafting (18 -45%). Long cross-clamp time, method of cardioplegia, depth of hypothermia, and patient age are some of the risk factors. We planned this study to ascertain the effect of crystalloid or tepid blood cardioplegia (CP) on conduction disturbances. Methods: One hundred patients were randomly divided into two groups. The first group received tepid blood CP and the second received cold crystalloid CP. St. Thomas II CP was used as CCP and the same CP was mixed with blood with a ratio of 4:1 in the tepid CP group. In both groups as an initial bolus, a 10 to 15 ml/kg CP was infused with a pressure of 75 mmHg. Additionally, 400 ml of CP were given every 20 min during the cross clamping period in addition to infusion of 50 -100 ml of CP after each distal anastomosis. Blood samples for CK, CK-MB, LDH and Troponin T measurements were obtained at induction, before bypass, after cross clamping, before de-clamping, after de-clamping and after bypass. Postoperative ECGs were analyzed by a cardiologist. Results: There were no deaths in both groups but the mean hospitalization was 8.4 F 1.7 days in group I, and 14.4 F 3.1 days in group II ( P = 0.004). Although there were significant rises in CK, CK-MB, LDH and Troponin T levels in both groups after CPB or de-clamping, the difference in increment between the two groups was not significant. Twelve patients in group II (24%) developed new fascicular blocks, four of these caused hemodynamic instability and needed inotropic treatment but only one was discharged with LAHB. Four patients in group I (8%) also developed new conduction disturbances within the first hour, but all completely resolved. Incidence of conduction disturbances was significantly increased in the crystalloid CP group ( P = 0.019). Conclusion: There were no significant differences in cardiac enzyme measurements between cold crystalloid and tepid blood CP, but crystalloid CP caused more fascicular blocks. We conclude that myocardial protection was equal in both cardioplegia methods whereas conduction disturbances have been assumed to be caused by cold injury to the conduction tissues.

Purpose: The most frequent arrhythmia after coronary artery bypass surgery is atrial fibrillation (AF). The prevention and treatment of this type of arrhythmia is subobtimal. Digitalis, b-blockers, diltiazem and amiodarone are the preferred drugs for the treatment. This study was designed to compare the effects of preoperatively started digitalis and atenolol in combination and separately, on the incidence of AF that occurs within 7 days following the operation. Materials and method: One-hundred and sixty patients who had similar demographic properties were randomly grouped as group I, that preoperatively received combined drug therapy (n ¼ 40), group II preoperatively used digitalis (n ¼ 40), group III atenolol (n ¼ 40), and group IV was the control group (n ¼ 40). Results: Postoperative AF incidence was 25, 15,4, and 17,9% in groups IV, III, and II, respectively, whereas it was 5% in group I which was lower than all other groups, but the difference was only significant between groups I and IV (P ¼ 0:012). Conclusion: The combined use of atenolol and digitalis preoperatively was considered as an efficient treatment for lowering the incidence of AF following coronary artery bypass surgery.

Stem cell transplantation after myocardial infarction has been claimed to restore cardiac function. Mesenchymal stem cells attract a lot of attention because of the feasibility of in vivo and ex vivo differentiation to cardiomyocytes and endothelial cells as well as their trophic effect on tissue repair. In this study, we investigated the efficacy of autologous bone marrow derived mesenchymal stem cells in improving heart function in patients with old myocardial infarction. Eight patients with old myocardial infarction and proper inclusion criteria were injected with mesenchymal stem cells at the time of coronary artery bypass grafting or percutaneous coronary intervention (test group) and compared with eight matched patients who received the same treatment without mesenchymal stem cell injection (control group). Evaluation of heart function was done by echocardiography plus single-photon emission computed tomography before and six months after the procedure. Serial clinical examina...

Objectives: The POST CABG (Post Coronary Artery Bypass Graft) Trial showed that aggressive lowering of low-density lipoprotein (LDL) cholesterol levels reduced the progression of atherosclerosis in saphenous vein grafts. In the extended follow-up phase, aggressive lowering of LDL cholesterol levels was associated with reduced rates of clinical events. Low-dose anticoagulation therapy did not reduce the progression of atherosclerosis. We conducted this analysis to determine the effects of both lipid-lowering and low-dose anticoagulation therapy on healthrelated quality of life (HRQL). Design: Randomized clinical trial, factorial design. Setting: Outpatients in five tertiary care medical centers. Patients: A cohort of 852 patients enrolled in the POST CABG Trial completed an HRQL questionnaire at baseline, and at the year 2 and year 4 follow-up visits. Intervention: Aggressive LDL cholesterol lowering vs moderate LDL cholesterol lowering, and low-dose warfarin vs placebo. Measurements: Domains included emotional status, basic physical and social functioning, perceived health status, symptoms of pain, a variety of physical symptoms, and global life satisfaction. Results: Overall, there were no indications of systematic differences among treatment groups for any of the HRQL parameters at baseline, year 2, or year 4. Conclusions: These data indicate that patients did not experience detrimental or beneficial effects on HRQL parameters while receiving LDL cholesterol-lowering therapy that had demonstrable benefits for treatment of atherosclerosis.

Background: Body mass index (BMI), age, left atrium (LA) dimensions and left ventricular ejection fraction (LVEF) have been linked to post-operative atrial fibrillation (POAF) after cardiac surgery. The aim was to better define the role of these risk factors. Methods: This study evaluated 249 patients (without prior atrial dysrhythmia) undergoing cardiac or aortic surgery . Prior to surgery the following data were collected: age (yrs), BMI (kg/m2), LA diameter (cm), LA area (cm2), LVEF (%), the presence of arterial hypertension (AH) and of diabetes, tyroid stimulating hormone (TSH, mU/L) and, creatinine (mg/dL). Results: Patients with (n. 127, 51%) and without POAF (n. 122, 49%) were compared. No difference was observed for sex, LA diameter, LA area, LVEF, TSH and diabetes. Instead, patients with PoAF had higher values of age, BMI, creatinine and a greater prevalence of AH and Bentall procedures. Multivariable analysis showed that the only independent predictors of PoAF were: age (O...

Background-Stroke after cardiac surgery is a devastating complication that leads to excess mortality and health resource utilization. The purpose of this study was to identify risk factors for perioperative stroke, including strokes detected early after cardiac surgery or postoperatively. Methods and Results-Data were obtained from 2972 patients undergoing coronary artery bypass graft and/or valve surgery. Patients Ն65 years old and those with a history of symptomatic neurological disease underwent preoperative carotid artery ultrasound scanning. Intraoperative epiaortic ultrasound to assess for ascending aorta atherosclerosis was performed in all patients. New strokes were considered as a single end point and were categorized with respect to whether they were detected immediately after surgery (early stroke) or after an initial, uneventful neurological recovery from surgery (delayed stroke). Strokes occurred in 48 patients (1.6%); 31 (65%) were delayed strokes. By multivariate analysis, prior neurological event, aortic atherosclerosis, and duration of cardiopulmonary bypass were independently associated with early stroke, whereas predictors of delayed stroke were prior neurological event, diabetes, aortic atherosclerosis, and the combined end points of low cardiac output and atrial fibrillation. Female sex was associated with a 6.9-fold increased risk of early stroke and a 1.7-fold increased risk of delayed stroke. In-hospital mortality of patients with early (41%) and delayed (13%) strokes was higher than that of other patients (3%, Pϭ0.0001). Conclusions-Most strokes after cardiac surgery occurred after initial uneventful recovery from surgery. Women were at higher risk to suffer early and delayed perioperative strokes. Atrial fibrillation had no impact on postoperative stroke rate unless it was accompanied by low cardiac output syndrome. (Circulation. 1999;100:642-647.

The results for mitral valve reconstruction are compared with those for prosthetic mitral valve replacement. Methods: From January 1976 to January 1996, 223 patients with ischemic mitral insufficiency underwent mitral valve reconstruction (n = 152) or prosthetic mitral valve replacement (n = 71). Coronary artery bypass grafting was performed in 89% of cases of mitral reconstruction and 80% of cases of prosthetic replacement. In the group undergoing reconstruction, 77% had valvuloplasty with a ring annuloplasty and 23% had valvuloplasty with suture annuloplasty. In the group undergoing prosthetic replacement, 82% of patients received bioprostheses and 18% received mechanical prostheses. Results: Follow-up was 93% complete (median 14.6 mo, range 0-219 mo). Thirtyday mortality was 10% for mitral reconstruction and 20% for prosthetic replacement. The short-term mortality was higher among patients in New York Heart Association functional class IV than among those in classes I to III (odds ratio 5.75, confidence interval 1.25-26.5) and was reduced among patients with angina relative to those without angina (odds ratio 0.26, confidence interval 0.05-1.2). The 30-day death or complication rate was similarly elevated among patients in functional class IV (odds ratio 5.53; confidence interval 1.23-25.04). Patients with mitral valve reconstruction had lower short-term complication or death rates than did patients with prosthetic valve replacement (odds ratio 0.43, confidence interval 0.20-0.90). Eighty-two percent of patients with mitral valve reconstruction had no insufficiency or only trace insufficiency during the long-term follow-up period. Five-year complication-free survivals were 64% (confidence interval 54%-74%) for patients undergoing mitral valve reconstruction and 47% (confidence interval 33%-60%) for patients undergoing prosthetic valve replacement. Results of a series of statistical analyses suggest that outcome was linked primarily to preoperative New York Heart Association functional class.

Background. This study analyzes a single institutional experience with minimally invasive mitral valve operations of 6 years, reviewing short-term morbidity and mortality and long-term echocardiographic follow-up data. Methods. Seven hundred fourteen consecutive patients had minimally invasive mitral valve procedures between November 1995 and November 2001; concomitant procedures included 91 multiple valves and 18 coronary artery bypass grafts. Of these 714 patients, 561 patients had isolated mitral valve operations (375 repairs, 186 replacements). Mean age was 58.3 years (range, 14 to 96 years; 30.1% > 70 years), and 15.4% of patients had previous cardiac operations. Arterial cannulation was femoral in 79.0% and central in 21%, with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%. Results. Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median ventilation time was 11 hours, intensive care unit time was 19 hours, and total hospital stay was 6 days. Complications for all patients included permanent neurologic deficit (2.9%), aortic dissection (0.3%); there was no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair patients had only trace or no residual mitral insufficiency. Conclusions. This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative morbidity and mortality and with late outcomes that are equivalent to conventional operations.

In order to assess the three-dimensional movement of the coronary arteries both during normal cardiac activity and after mechanical stabilization, a polypropylene black marker was placed in 10 pigs on the middle portion of the three main coronary branches. Marker motion was recorded for 10 s using two TV-digital cameras and was estimated with a precision of 50 microm. After stabilization with three different mechanical stabilizers (Medtronic, Genzyme, CTS-Guidant), a remnant coronary artery excursion of about 1.5-2.4 mm was found. There is a significant residual coronary artery motion after mechanical stabilization, which could affect the quality of anastomosis, especially in unfavourable situations.

The purpose of this study was to evaluate characteristics and outcomes of patients age Ն80 undergoing cardiac surgery. BACKGROUND Prior single-institution series have found high mortality rates in octogenarians after cardiac surgery. However, the major preoperative risk factors in this age group have not been identified. In addition, the additive risks in the elderly of valve replacement surgery at the time of bypass are unknown. We report in-hospital morbidity and mortality in 67,764 patients (4,743 octogenarians) undergoing cardiac surgery at 22 centers in the National Cardiovascular Network. We examine the predictors of in-hospital mortality in octogenarians compared with those predictors in younger patients. Octogenarians undergoing cardiac surgery had fewer comorbid illnesses but higher disease severity and surgical urgency than younger patients. Octogenarians had significantly higher in-hospital mortality after cardiac surgery than younger patients: coronary artery bypass grafting (CABG) only (8.1% vs. 3.0%), CABG/aortic valve (10.1% vs. 7.9%), CABG/mitral valve (19.6% vs. 12.2%). In addition, they had twice the incidence of postoperative stroke and renal failure. The preoperative clinical factors predicting CABG mortality in the very elderly were quite similar to those for younger patients with age, emergency surgery and prior CABG being the powerful predictors of outcome in both age categories. Of note, elderly patients without significant comorbidity had in-hospital mortality rates of 4.2% after CABG, 7% after CABG with aortic valve replacement (CABG/AVR), and 18.2% after CABG with mitral valve replacement (CABG/MVR).

Preoperative medication by inhibitors of angiotensin-converting enzyme (ACE) in coronary artery patients predisposes to vasoplegic shock early after coronary artery bypass grafting. Although in the majority of the cases this shock is mild, in some of them it appears as a situation, &quot;intractable&quot; to high-catecholamine dose medication. In this study we examined the possible role of prophylactic infusion of low-dose vasopressin, during and for the four hours post-bypass after cardiopulmonary bypass, in an effort to prevent this syndrome. In addition, we studied the influence of infused vasopressin on the hemodynamics of the patients, as well as on the postoperative urine-output and blood-loss. In our study 50 patients undergoing coronary artery bypass grafting were included in a blind-randomized basis. Two main criteria were used for the eligibility of patients for coronary artery bypass grafting: ejection fraction between 30-40%, and patients receiving ACE inhibitors, at lea...

Background— Numerous studies have shown that diabetes mellitus (DM) is not identified and, consequently, inadequately treated in a substantial proportion of the patients in the general population. We know very little about the extent and the consequences of undiagnosed diabetes in the risk group of patients with coronary heart diseases. The objective of this study was therefore to determine the prevalence and the risks of undiagnosed DM among patients with coronary artery bypass. Methods and Results— The data of 7310 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Depending on their diagnosis on admission and their fasting plasma glucose (FPG) level, these patients were classified as known diabetics, undiagnosed diabetics (FPG ≥126 mg/dL), or as nondiabetics (FPG &lt;126 mg/dL) and were compared in terms of their preoperative, intraoperative, and postoperative characteristics. Among the patients with coronary bypass that we examined, we fo...

Subperiosteal orbital hemorrhage (SPOH) following cardiac surgery has not been previously reported. We present a patient who developed diplopia and right eye proptosis immediately after cardiac surgery for a mitral valve repair and coronary artery bypass graft. A computed tomography (CT) study demonstrated a right superior SPOH. The diplopia and proptosis resolved spontaneously within 4 weeks. Follow-up CT showed complete resolution of the SPOH.

Subperiosteal orbital hemorrhage (SPOH) following cardiac surgery has not been previously reported. We present a patient who developed diplopia and right eye proptosis immediately after cardiac surgery for a mitral valve repair and coronary artery bypass graft. A computed tomography (CT) study demonstrated a right superior SPOH. The diplopia and proptosis resolved spontaneously within 4 weeks. Follow-up CT showed complete resolution of the SPOH.

Background: Preoperative renal dysfunction is an important risk factor in cardiac surgery. Thus, the association between creatinine clearance (ClCr) and mechanical ventilation time and ICU length of stay, independent of other established preoperative risk indicators, was analyzed. Methods: In our study, 156 consecutive patients underwent open-heart surgery at the