Biomedical subjects
Publications and source records attributed to F Simonet.
We report a case of a 71-year-old hypertensive female patient presenting with haemoptysis and retrosternal pain from a leaking pseudo-aneurysm associated with a Dacron onlay patch used to repair a coarctation of the aorta 27 years earlier. This case illustrates a late and potentially fatal complication of this type of operation and describes a recent technique to reach the exact diagnosis and location of the aneurysm.
Oligo-elements such as zinc (Zn), selenium (Se) and copper (Cu) have a significant influence on the function of the immune system. Various immunological and inflammatory changes are known to occur in patients undergoing cardiopulmonary bypass. The aim of this study was to evaluate changes in serum oligo-elements levels during and following cardiopulmonary bypass. The serum levels of Zn, Se and Cu were determined in 67 consecutive patients, with coronary artery disease admitted for coronary artery bypass grafting. Blood samples for oligo-elements, analysis were withdrawn into metal-free tubes just prior to the start of cardiopulmonary bypass; at 30, 60 and 90 min into cardiopulmonary bypass; following weaning from cardiopulmonary bypass; 30 min after termination of cardiopulmonary bypass; at 24 h; and on the 5th postoperative day. Trace elements analyses were performed using atomic absorption spectrophotometry. Interleukin 6 and 8, as well as serum albumin, creatine phosphokinase, lactate dehydrogenase and creatine phosphokinase-MB fractions were also analyzed. The mean age was 63 +/- 9 years and 91% (61) were men. The mean preoperative left ventricular function was 52 +/- 12%, Canadian Cardiovascular Society (CCS) angina class was 3.7 +/- 0.5 and 30% (20) of the operations were re-do's. All patients had normothermic cardiopulmonary bypass. Mean cardiopulmonary bypass-time was 85 +/- 31 min. One patient was lost for the recovery sampling (hospital mortality, 1.5%). Nine patients had a postoperative cardiac index < 2.0 liter/min per m2, which required pharmacological support and additional intra-aortic balloon pump in two of them. Other postoperative complications were few. There was a rapid depletion of S-selenium and S-Zn levels, which were halved at 30 min after cardiopulmonary bypass and remained low throughout the study period. The Cu/Zn ratio increased significantly at the start of cardiopulmonary bypass, which indicated an inflammatory reaction and was not normalized until the 5th postoperative day. Length of ischemia time, presence of diabetes. hypertension and hyperlipidemia did not influence the results, while a prolonged cardiopulmonary bypass-time > 120 min resulted in a higher Cu/Zn ratio than observed for shorter cardiopulmonary bypass-times. This indicates a more profound inflammatory response. Inflammatory parameters responded in the same manner as described earlier by others. These data indicate that severe loss of various oligo elements occur in patients undergoing coronary artery bypass grafting and suggests that a supplementary administration of zinc and perhaps also selenium could be appropriate during cardiopulmonary bypass.
The sequential bypass grafting technique has many advantages over coronary artery bypass grafting with single grafts. The aim of this study was to evaluate the consequences of sequential bypass graft failure. Between 1 January 1984 and 31 December 1996, 3846 patients underwent primary coronary artery bypass vein grafting. A total of 3490 patients received sequential vein bypass grafts and 356 patients received single vein bypass grafts (9%). There were 6177 sequential bypass grafts (3490 postero-lateral grafts (56%) and 2687 in the antero-lateral position (44%)) and 1468 single grafts (972 vein grafts and 496 internal thoracic artery grafts). Overall, there were 80 hospital deaths (2.1%). Mortality in relation to type of grafts used was: 13 deaths in 356 patients with only single graft (3.7%) and 67 deaths in 3490 patients who received sequential vein grafts (1.9%). Of 3766 hospital survivors, 3731 were followed for an average of 76 months. During follow-up, 85 patients died (2.3%), 15 patients (0.4%) underwent cardiac transplantation and 52 (1.4%) had re-do coronary artery bypass vein grafting. Graft-percutaneous transluminal coronary angioplasty was performed in 56 patients (1.5%), 37/1390 single bypass grafts (2.7%) and 19/6023 sequential bypass grafts (0.3%). There were 272/6023 symptomatic sequential graft occlusions (4.5%) (182 were in postero-lateral position and 90 in the antero-lateral position). There were 66/667 single vein graft occlusions (9.9%) and 15 symptomatic internal thoracic artery graft occlusions (2.1%) during follow-up. In 97% of patients, presenting symptoms of postero-lateral sequential bypass graft occlusion took the form of a renewed angina with a myocardial infarction rate of 3% and a mortality rate of 7%. Corresponding figures for antero-lateral sequential bypass grafts were 22, 78 and 68%, and anterior single vein bypass grafts were 70, 30 and 15%, respectively. The overall 10-year survival rate in patients with sequential bypass grafts was 81.2% and the cumulative patency rate (1464 angio-controls of 2576 sequential vein grafts) was 72.2%. A symptomatic occlusion of a postero-lateral sequential vein bypass results in a low incidence of myocardial infarction with low mortality, when the terminal anastomosis is connected to a high flow vessel. An antero-lateral sequential vein bypass graft has better long-term patency than single vein bypass, but should occlusion occur, it would usually be associated with a higher myocardial infarction and mortality rates than a single vein graft. The highest risk for failure of a sequential graft in the antero-lateral position occurs when the left anterior descending artery (LAD) is small or severely diseased. In this situation the single graft technique with internal thoracic artery appears to be safer.
In recent years coronary artery bypass grafting (CABG) has been extended to include patients with very low left ventricular ejection fractions (LVEF), also frequently with co-existing mild to moderate mitral valve regurgitation (MR). The question is, should MR be corrected simultaneously with a myocardial revascularization or not? Between January 1990 and December 1996, 82 patients with preoperative LVEF < or = 0.25 and echocardiographic evidence of co-existing MR without chordal or papillary muscle rupture (Grade I-28%, II-35%, III-32% and IV-5%) underwent primary CABG. None of them underwent simultaneous mitral valve surgery. The mean preoperative LVEF was 0.17 +/- 0.04 (0.10-0.25), mean PAP 43.8 +/- 15.9 mmHg. An average of 4.4 +/- 1.5 grafts/ patient were placed. The overall mortality was 3.7% (3/82). Transient postoperative low cardiac output syndrome occurred in 24 patients (29%). Thirty-two patients (39%) had no postoperative complications at all. Seventy-nine hospital survivors were followed up over a period of 18 months (6-48 months) on average. There was one death (8 months post-operatively) and 2 graft occlusions, not requiring redo surgery. At the end of follow up echocardiography showed that 45 patients had no MR at all and 28 patients had MR-Grade I, a total of 73 patients (94%). Five patients had Grade II-III MR, none of them requiring mitral valve surgery. All patients improved their NYHA functional class, from 3.5 +/- 0.7 to 1.8 +/- 0.5 and the LVEF from 0.17 +/- 0.04 to 0.46 +/- 0.08, p < 0.001. Moderate to severe co-existing MR (Grade II-IV) seems to normalize after the myocardial revascularization and should therefore not be surgically corrected at the primary operation, if there are no echocardiographic evidence of chordal or papillary muscle rupture. Peroperative control echocardiography is recommended.
Arterial hypertension is a major risk factor for myocardial infarction and cardiovascular disease. The presence of left-ventricular hypertrophy in hypertensive patients is associated with a risk of mortality from cardiovascular disease three times greater than the risk with hypertension alone. Hypertension is also associated with an increased mortality and morbidity following myocardial revascularization. This risk is further augmented when left ventricular hypertrophy is present. Calculation of the ventricular mass by echocardiographic methods seems important, particularly in patients with hypertension and poor preoperative left-ventricular function (LVEF < or = 40%), in order to estimate operative risks. In this high-risk group the outcome of surgical revascularization can be improved by utilizing a preoperative intra-aortic balloon support.
BACKGROUND: Reoperative coronary artery bypass grafting (redo CABG) is associated with an increased operative risk compared with primary CABG. Because the hospital mortality in redo CABG is known to be influenced by poor left ventricular function (left ventricular ejection fraction < or = 0.40), unstable angina, and left main stem stenosis greater than or equal to 70%, a preoperative intraaortic balloon pump (IABP) support could be beneficial to improve the outcome in high-risk redo CABG. METHODS: Between June 1994 and October 1996, 48 high-risk patients underwent redo CABG and were randomized into the following groups: group 1 (24 patients) who received preoperative IABP treatment on average 2 hours before cardiopulmonary bypass, and group 2 (24 patients) who received no preoperative IABP and served as controls. Mean age was 65 years and 90% (43 patients) were men. Forty-one patients had preoperative left ventricular ejection fraction less than or equal to 0.40 (85%), 38% (18 patients) had left main stem stenosis greater than or equal to 70%, and 54% (26 patients) had unstable angina preoperatively. Preoperative patient characteristics did not differ between the groups. RESULTS: The time on cardiopulmonary bypass was shorter in group 1, 86 versus 110 minutes (p = 0.006). There were no hospital deaths in group 1, but four deaths occurred in the control group (p = 0.049). Cardiac index rose significantly preoperatively after introduction of the IABP in group 1. Cardiac index was significantly higher postoperatively in group 1 compared with group 2 and remained significantly higher during the first 24 hours after cardiopulmonary bypass. Significantly fewer patients in the IABP group had postoperative low cardiac output (4 versus 13 patients). Nine patients in group 2 required IABP support postoperatively for 4.1 +/- 1.7 days. Only 2 patients in group 1 needed IABP postoperatively, and their IABPs were successfully removed on the first postoperative day. The preoperative IABP-supported patients had a shorter intensive care unit stay, 2.4 +/- 0.8 days compared with group 2, 4.5 +/- 2.2 days (p = 0.007), as well as a shorter hospital stay. The preoperative IABP treatment was found to be cost-effective. CONCLUSIONS: Preoperative treatment with IABP in high-risk redo CABG patients is an effective modality to prepare these patients to have their myocardial revascularization in an as nonischemic situation as possible, which resulted in a significantly lower hospital mortality, fewer instances of postoperative low cardiac output, and shorter stays in both the intensive care unit and the hospital.
OBJECTIVES: The number of coronary artery disease reoperations is increasing. The aim of this paper is to identify risk factors and evaluate the results of REDO coronary artery bypass grafting (CABG). MATERIAL: Between January 1984 and October 1994, 594 patients underwent REDO-CABG and 3157 underwent primary-CABG. The mean age was 62 years with 84% men. Hypertension, hyperlipidemia, insulin dependent diabetes, smoking and renal insufficiency were all more frequent in the REDO-group. A significantly higher number of patients undergoing REDO-CABG were in the Canadian Cardiovascular Society (CCS) angina class 3 and 4, had instable angina, had left main stem stenosis of greater than 70% and 3-vessel disease compared to those undergoing primary-CABG. The mean preoperative left ventricular function (LVEF) was 49.8 (REDO) vs. 58.2%, with a P value of less than 0.001. RESULTS: The overall postoperative mortality rate for REDO-operations was 9.6 (57/594) vs. 2.8% for primary-CABG. Patients with a reoperative interval of more than 1 year had an 8.9% mortality rate, compared to those reoperated less than 1 year after the initial CABG, where the mortality was 21% with a P value of less than 0.05. Postoperative low cardiac output syndrome, intraaortic balloon pump support, prolonged ventilatory support (> 24 h), hemorrhage and gastrointestinal complications were prominent features of the REDO-group (all P < 0.01). Urgent operation, CCS class 3 and 4, LVEF of less than 40%, generalized arteriosclerotic disease and advanced age (> 80 years) were independent risk factors for postoperative death in both groups. Preoperative renal insufficiency, diabetes and short interval from primary-CABG were added risk factors in the REDO-group. The 5-years survival rate after REDO-CABG was 89%, while the cardiac event-free survival rate was 79% and at 7 years 84 and 62%, respectively. CONCLUSIONS: Reoperative CABG is effective, but has an increased operative mortality and morbidity. The long-term results are encouraging. Unstable angina, poor preoperative left ventricular function, renal insufficiency, insulin dependant diabetes and an interval shorter than 1 year of the initial operation were independent riskfactors for mortality.
OBJECTIVE: The intra-aortic balloon pump (IABP) is an established additional support to pharmacological treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The effect of preoperative IABP in high risk patients was evaluated. METHODS: Between June 1994 and March 1996 all high risk patients for CABG (two or more of these criteria: Left ventricular ejection fraction (LVEF) < or = 40%, left main stem stenosis > or = 70%, REDO-CABG, unstable angina) were randomized into either of 3 groups: (1) IABP 1 day prior to surgery, (2) IABP 1-2 h prior to CPB and (3) no preoperative IABP, controls. EXCLUSION CRITERIA: cardiogenic shock preoperatively. Fifty-two patients have entered the study-group 1 (13 patients), group 2 (19 patients) and group 3 (20 patients). Preoperative patient characteristics and operative data revealed no group differences. There were 56% REDO's, unstable angina 59%, LVEF < or = 40%, 87% (34.0 +/- 11.6%) and left main stem stenosis in 35%. RESULTS: The CPB-time was shorter in groups 1 and 2 88.7 +/- 20.3 min than in group 3 105.5 +/- 26.8 min, P < 0.001, while ischemia time did not differ. Hospital mortality was higher in group 3, 25% vs. 6% (groups 1 and 2). Postoperative low cardiac output was seen in 12 patients (60%) in group 3 vs. 6 patients (19%) in groups 1 and 2, P < 0.05. Cardiac index increased significantly prior to CPB in groups 1 and 2. After CPB cardiac index was significantly higher in groups 1 and 2 compared to Group 3 and continued to increase. The IABP was removed after 3.1 +/- 1.0 days in group 3 vs. 1.3 +/- 0.6 days in groups 1 and 2, P < 0.001. In group 3, 11 patients required IABP postoperatively compared to only 4 patients in groups 1 and 2. ICU stay was shorter in groups 1 and 2--2.3 +/- 0.9 days vs. 3.5 +/- 1.1 days for group 3, P = 0.004. All patients received dopamin postoperatively, however in a lower dose in groups 1 and 2, 4.5 vs. 13.5 microg/kg/min. Dobutamine was added in 23% of the patients (group 1), 32% (group 2) and 95% (group 3). Adrenalin/amrinonum was required in 40% of the patients in group 3, 5% in group 2 and none in group 1. Group 1 patients had a better improvement of cardiac performance than group 2, while other parameters did not differ. Three months follow up of hospital survivors showed no group differences. CONCLUSIONS: The use of preoperative IABP in high risk patients lowers hospital mortality and shortens the stay in ICU, due to improved cardiac performance, compared to a controls. The procedure was cost-beneficial. One day preoperative IABP treatment improves cardiac performance more than 1-2 h preoperative IABP treatment, but does not significantly affect the outcome in terms of hospital mortality or postoperative morbidity.
Poor left-ventricular function, hypertension, and left-ventricular hypertrophy in patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) are associated with increased operative risks. Between June 1994 and March 1996, 33 patients undergoing CABG, were randomized into 2 groups. One group (IABP group, n = 19) received IABP treatment on average for 2 hours prior to CPB, the other group (control group, n = 14) had no preoperative IABP, Cardiac performance was measured pre- and postoperatively by Swan-Ganz catheter. Mean age was 65 years and 90% were men. All patients had a preoperative LVEF < or = 40% (mean 32.6 +/- 11.1%), 3-vessel disease, established hypertension (WHO criteria), and LV hypertrophy (ventricular mass > or = 136 g/m2 [men] or > or = 110 g/m2 [women]). Ischemia time was similar in both groups while CPB-time was shorter in the IABP group, p < 0.05. There were no hospital deaths in the IABP group, but 3 in the control group suffered postoperative low cardiac output. Nine patients (64%) in the control group required IABP support postoperatively, but only 20% of the patients in the IABP group had a shorter ICU stay, 2.4 +/- 0.9 vs. 3.4 +/- 1.1 days, p < 0.01. Cardiac index increased significantly in the IABP group prior to CPB and was higher compared to control, p < 0.001. Five min after CBP cardiac index was higher in the IABP group than in the control group, p = 0.013, and continued to increase thereafter, while no further improvement was observed in controls. Preoperative IABP treatment in hypertensive patients with CAD, low LVEF and LV hypertrophy who are undergoing CABG is beneficial. An improved cardiac performance pre- and postoperatively was associated with a lower rate of hospital mortality and less postoperative morbidity, as well as shorter ICU stay. The treatment is cost-beneficial.
BACKGROUND: With a steady increase in the number of elderly patients requiring coronary artery bypass grafting (CABG), a larger portion of elderly patients will also become candidates for reoperative CABG. Scepticism still exists as to whether this operation is justified in older patients. The purpose of this study was to examine the effect of increasing age on the outcome after reoperative CABG. METHODS: Between January 1, 1990 and June 30, 1996 563 patients underwent isolated reoperative CABG, and were included in this retrospective analysis. Patients who had combined procedures were excluded. The patients were divided by age into two groups: those aged 69 years or less (n = 507), and those older than 70 years (n = 56). Hospital mortality and morbidity for each group was compared. Medium-term survival for each group was compared with that of their age-matched population derived from Swiss life tables. RESULTS: The patients aged 70 years and older had a higher New York Health Association functional class, and more patients had unstable angina requiring urgent surgery than did the younger patients. The elderly also showed an over-representation of diabetes and multifocal vascular disease (generalized arteriosclerotic disease), and there was a higher number of patients with triple-vessel disease and left stenosis (> or = 70%) in this group. Patients aged 70 years and older received fewer distal anastomoses (3.0 versus 3.6; P < 0.01), and had a longer cardiopulmonary bypass time compared with the younger patients, but the ischemia time was similar in both groups. Hospital mortality was higher in patients older than 70 years (7.1 versus 17.9%). There was an increased frequency of postoperative low cardiac output and a higher incidence of gastrointestinal complications and transient renal failure amongst the elderly patients (> or = 70 years). Despite a higher hospital mortality rate and slightly increased morbidity the 5-year survival was excellent, and comparable with the age-matched population in both groups [89.6% (< 70 years) and 76.2% (> or = 70 years)]. The cardiac event-free survival was 79.8% (< 70 years), and 69.9% (> or = 70 years) after 5 years. CONCLUSION: An acceptable early mortality and long-term survival together with good functional long-term results support the justification of reoperative CABG in older patients, at least up to the age of 80 years.
The intra-aortic balloon pump (IABP) is an established additional support to pharmacologic treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The physiologic effect of IABP are: increased coronary perfusion and decreased left ventricular outflow impendance. The effects of preoperative IABP are not established. The aim of this study was to define indications and evaluate the effect of preoperative IABP support. Between January 1, 1990 and December 31, 1994, 1999 patients underwent CABG [318 REDOCABG, 15.9% and 1681 primary CABG, 84.9%]. From January to June 1994, 80 of 1811 patients (4.5%) required additional intra-aortic balloon pump (IABP) support postoperatively, 35 after REDO (21%) and 45 after primary CABG, 3%. Indication for IABP was failure to wean from cardiopulmonary bypass (CPB), despite maximal dose pharmacological support. The overall hospital mortality was 11.6% after REDO's and 2.1% after primary CABG, p < 0.001. In those where IABP was required the mortality rate was 67.7% after REDO and 36.8% after primary CABG, p < 0.01. Multivariate analysis identified preoperative unstable angina as independent risk factor for mortality (p < 0.001). REDO-CABG, LVEF < 40%, diffuse coronary artery disease and left main stem stenosis were identified as riskfactors for mortality when combined with one and another in a combination of at least two factors. In the IABP supported group mean ICU stay was 5.4 +/- 1.8 days. Thereafter the concept of preoperative use of IABP was introduced and presence of at least two of the above identified riskfactors served as indication for preoperative IABP treatment. The IABP was placed in the operating room at induction of anesthesia (1-1.5 hr prior to cross-clamping). Between June and December 1994, 19 of 188 patients received a preoperative IABP (9.0%). There were no balloon related complications. The mortality rate was 21%. Weaning from CPB was easy and in 30% of the cases the IABP was not necessary postoperative. In 90% of the pumps were removed within 24 hours postoperative. The mean ICU stay was 2.1 +/- 0.9 days. The first part of this study identified riskfactors for mortality after CABG and in the second series the efficacy of preoperative IABP treatment in "high-risk" patients was demonstrated. Preoperative IABP support in these patients seems also cost efficient due to lower mortality and shorter stay in intensive care unit in this group of patients.
Reactive thrombocytosis (RT, platelet counts > 400 x 10(3)/mm3) following coronary artery bypass grafting (CABG) has previously been reported to occur frequently (20%) and is associated with thrombotic complications, e.g. vein graft occlusion. This prospective study was undertaken in an attempt to identify the underlying causes of RT following CABG. 40 consecutive patients undergoing elective CABG entered the study between December 1 1994 and April 15 1995. Patient characteristics, operation data, cardiopulmonary data and postoperative complications (30 parameters) were evaluated together with routine blood chemistry, hematology, hemostasis and anti-inflammatory parameters (25 parameters/ day, preoperatively until the 9th postoperative day). 15 patients developed RT and 25 served as controls. Patient characteristics did not differ. Operation data, cardiopulmonary bypass data and post-operative complications revealed no group differences, neither did preoperative laboratory results, except that S-cholesterol was higher in the RT-group (6.2 +/- 0.9 vs. 5.3 +/- 0.9, p < 0.018). All blood findings were without group differences throughout the entire study period, except platelet counts, platelet size (PWD) and mean platelet volume (MPV), and AT III levels on the 7th postoperative day, which were significantly lower in controls compared to RT. RT patients had a less marked drop in platelet count immediately after cardiopulmonary bypass than non-RT, together with an increased MPV, but without differences in PWD. There was a significantly higher platelet count in the RT group on the 3rd postoperative day, which remained higher throughout the study period. This study has again found RT frequently occurring after CABG (30%). Preoperative S-cholesterol was significantly higher in the RT group, while other parameters did not differ in RT vs. non-RT. It is therefore possible that RT is linked to a lipid dysfunction, and further studies are ongoing.
BACKGROUND: Blood conservation remains an important element for patients undergoing cardiac operations with cardiopulmonary bypass. Preoperative platelet-rich plasma (PRP) harvest is an autologous blood conservation method. The efficacy of preoperative PRP harvest and post-cardiopulmonary bypass reinfusion on postoperative bleeding and need for postoperative blood transfusion was evaluated in patients undergoing redo coronary artery bypass grafting in a prospective, randomized manner. METHODS: All adult patients admitted for redo coronary artery bypass grafting entered into the study. The PRP harvest aim was 20% or more of the total estimated circulating platelets. Immediately preoperatively three sequestration cycles were performed. The PRP was reinfused after weaning from cardiopulmonary bypass. One hundred seven parameters/patient were recorded. There were 20 patients in the RPR group and 20 controls (without PRP harvest). RESULTS: Patient characteristics, operative data, and preoperative hematologic parameters did not differ between the groups. In the PRP group, the mean platelet count in the PRP was 864 +/- 139 x 10(3)/microL, and the platelet yield was 27% +/- 5% (range, 20% to 37%). The average total chest tube blood loss was 423 mL (PRP) compared with 1,462 mL (controls; p < 0.001). Fourteen patients in the control group required blood transfusions postoperatively compared with only 1 patient in the PRP group (p < 0.001). Postoperative fluid requirements were also significantly greater in the control group (p < 0.001). Postextubation gas exchange was significantly better in the PRP group compared with controls (p < 0.01). Postoperative ventilation time and intensive care stay were significantly shorter in patients in the PRP group. CONCLUSIONS: A preoperative PRP harvest of 20% or more of the total platelets and reinfusion of the PRP after cardiopulmonary bypass resulted in significantly less postoperative blood loss and decreased fluid and blood transfusion requirements compared with controls. Postextubation gas exchange, ventilation time, and time required in the intensive care unit were also better, and the method was found cost-effective.
Adult respiratory distress syndrome, characterized by high permeability pulmonary oedema caused by endothelial cell damage, resulting in refractory hypoxemia, has a very high mortality. Cardiopulmonary bypass is said to be responsible for the development of adult respiratory distress syndrome after cardiac surgery. The present study was performed in order to identify predicting and aetiological factors of adult respiratory distress syndrome and multiple organ failure after cardiac surgery. Between January 1984 and December 1993, 3848 patients underwent cardiac surgery with cardiopulmonary bypass in the authors' institution, and were analysed in a retrospective manner. The operations performed were 3444 coronary artery bypass grafts (CABG), 267 valve and 137 combined (CABG + valve) procedures. The incidence of adult respiratory distress syndrome was 1.0% (38 of 3848) with an overall mortality rate of 68.4% (26 patients); 24 of these died from multiple organ failure. Multivariate regression analysis identified hypertension, current smoking, emergency surgery, preoperative New York Heart Association (NYHA) class 3 and 4, low postoperative cardiac output and left ventricular ejection fraction < 40% as significant, independent predictors for adult respiratory distress syndrome. Combined cardiac surgery and diffuse coronary disease were also significant predictors; cardiopulmonary bypass time was not. Thirty-six of the 38 patients that later developed adult respiratory distress syndrome had low postoperative cardiac output, 12 requiring intra-aortic balloon pump support. The remaining two had severe hypotension caused by postoperative bleeding. Twenty-six adult respiratory two had severe hypotension caused by postoperative bleeding. Twenty-six adult respiratory distress syndrome patients (68%) had confirmed gastrointestinal complication (e.g. intestinal ischaemia). Adult respiratory distress syndrome is a rare complication after cardiac surgery but is associated with a very high mortality. Preoperative predictors were identified. Cardiopulmonary bypass alone was not found to be an important factor. Postoperative low cardiac output leading to splanchnic hypoperfusion may be the most important single factor in developing adult respiratory distress syndrome after cardiac surgery.
Reoperative (redo) coronary artery bypass grafting is an efficient treatment for patients with progressive coronary artery disease and those with conduit failure. Previous studies have demonstrated that a short time interval between primary and redo coronary artery bypass grafting is associated with a significantly higher mortality rate. In the present report this particular group have been specifically evaluated. Between 1 January 1990 and 1 October 1994, 383 consecutive patients underwent redo coronary artery bypass grafting. Thirty-three patients (8.6%) were operated on at < or = 1 year (group 1) and 350 patients at > 1 year after the primary bypass (group II). The main indications for redo in group I were graft failure (58%), incomplete revascularization (39%) and progress of disease (3%); respective values in group II were 26% 15%, and 23%. In addition, 36% of patients in group II had combinations of complications. Patient characteristics did not differ between groups, except a higher incidence of insulin-dependent diabetes in group I (P < 0.05). There was a higher incidence of left main stem stenosis of > 70% in group I (P < 0.05). Group I patients had a longer aortic cross-clamping time and needed thromboendarterectomy and patching of coronary vessels more often than did those in group II (P < 0.05). The internal mammary artery had been more frequently used at the primary coronary artery bypass grafting in group I (P < 0.01). The overall mortality rate was 8.9%; that in group I was 18% and in group II, 8% (P < 0.05). There was a higher incidence of non-fatal myocardial infarction and a need for prolonged ventilatory support (> 24 h) in group I. Other postoperative complications did not differ. Significant risk factors for mortality in group I were preoperative Canadian Cardiovascular Society class > or = 3, unstable angina, need for urgent operation and left ventricular ejection fraction < 40%, and > or = 70% left main stem stenosis. In group II, the risk factors were: unstable angina, urgent operation, left ventricular ejection fraction < 40%, internal mammary artery not used at primary coronary artery bypass grafting and the need for coronary thromboendarterectomy. The 3-year survival and cardiac event-free survival did not differ between the groups. This study has confirmed that early redo coronary artery bypass grafting (< or = 1 year from primary bypass) is associated with an increased operative risk.
OBJECTIVES: Open chest (OC) and subsequent delayed sternal closure (DSC) has been described as a useful method in the treatment of the severely impaired heart after cardiac surgery. METHODS: Prolonged open chest was used in 142 to 3373 adult cardiac operations (4.2%) between January 1987 and December 1993. The indications were: hemodynamic compromise (121), intractable bleeding (9) and arrhythmias (12). Delayed sternal closure was carried out in 123 of 142 patients at a mean of 2.0 +/- 1.4 days (range 0.5-8 days). Open chest and DSC were used proportionally more frequently after combined cardiac surgery (28/293, 9.6%) than after coronary artery bypass grafting (CABG) alone (108/2891, 3.7%) or valve operation (6/230, 2.6%). RESULTS: Ninety-seven of the 123 who had DSC (78.9%) survived and were discharged an average of 8.6 +/- 4.2 days after closure. Fourty-five patients died: 19 before DSC and 26 after this method. Mortality was related to indications for OC: when the indication was low cardiac output the mortality was 38.6%, for hemodynamic collapse on closure 0%, diffuse bleeding 33.3% and arrhythmias 27.3%. Delayed sternal closure in patients without intraaortic balloon pump support was more likely to be successful (mortality rate 4/25, 16.0% versus 35/76, 46.3%, P < 0.01). Superficial sternal wound infection occurred in 2 of 123 (1.6%) patients after DSC, mediastinitis in 1 (0.8%) and sternal dehiscence in 3 (2.4%) patients, which does not differ from a control population that had primary sternal closure. The follow-up of 97 survivors at an average of 28 +/- 4 months revealed an improvement of NYHA class by 1.4 +/- 0.4. There were 16 deaths (13 cardia-related) during the follow-up period and 3 redo CABG. One case of sternal osteomyelitis occurred without any other late sternal morbidity. CONCLUSIONS: This study shows that OC with DSC is a beneficial adjunct in the treatment of postoperatively impaired cardiac function, profuse hemorrhage and persistent arrhythmias. It can be performed without increased sternal morbidity. Long-term results are also encouraging.
Arterial hypertension is though to be associated with reduced coronary vasodilator reserve in the coronary microcirculation. Increased ventricular mass and coronary arteriolar abnormalities are the dominant features in patients with severe hypertension, while large-vessel coronary disease is the predominant feature in patients with mild hypertension. In the present study we have evaluated how hypertension influences the outcome of coronary artery bypass grafting (CABG), with emphasis on patients with preoperative left-ventricular ejection fraction (LVEF) < or = 25%. Between January 1, 1990 and November 1, 1994, 77 consecutive patients with LVEF < or = 25% (Hypertensive, n = 38 [group I] and normotensive, n = 39 [group II] underwent CABG. During the same time period 2289 patients with LVEF > 25% underwent CABG (Hypertensive, n = 870 [group III] and normotensive, n = 1419 [group IV]) and were studied for comparison. Mean age (64 years), sex distribution (86% men), and other classical risk factors did not differ between the groups, except a higher incidence of insulin-dependent diabetes in patients with LVEF < or = 25%. There were 18% reoperative CABG, 91% of the patients were Canadian Cardiovascular Society's (CCS) angina class 3 and 4 preoperatively, 38% had unstable angina, and 35% underwent urgent surgery (within 24 hours of admission). Angiography and operation data did not differ significantly between the groups. Hospital mortality in group I was 5.3% and in group II 15.4%, p < 0.008. In group III it was 6.3% and in group IV 2.2%, p < 0.001. Postoperative low cardiac output occurred in 18% (group I) and 39% (group II), p < 0.05, and only in 5% in groups III and IV, p < 0.001. Non-fatal myocardial infarction and other postoperative complications revealed no group differences. LVEF and CCS class improved from 1 month postoperatively in groups I and II, however, significantly more in group I (hypertensives), p < 0.001. Hypertensive patients with poor left-ventricular function preoperative to were found to have a lower hospital mortality and incidence of postoperative low cardiac output than normotensiven with LVEF < or = 25%. Hypertensive patients also had a better improvement of their left-ventricular function and CCS class than normotensiven. Left-ventricular hypertrophy and previous myocardial infarction were predictors for mortality in patients with LVEF > 25%. Patients with LVEF < or = 25% showed the same tendency, though not statistically significant.
The management of patients with coexisting severe carotid and coronary artery disease continues to be controversial. To evaluate the actual risks we have reviewed our experience of 92 patients that underwent simultaneous cardiac surgery and carotid thrombendarterectomy (TEA) over a 10 year period. The mean age was 65 +/- 7 year (41-80), 75% were men. There were 11 REDO cardiac procedures. There were 15 symptomatic and 77 asymptomatic carotid artery stenosis, including 21 with bilateral carotid disease. Mean preop.LVEF was 57.4% (15-80%). Carotid TEA was performed under hypothermia (26 degrees C), preferably with beating heart after an equilibration period of 10 min. The overall mortality was 5.4% (5 patients). 4 of the deaths were reoperative cardiac surgery. Non-fatal myocardial infarction occurred in 1 patient. Postop. neurological complications were diagnosed in 7 patients (8%), 3 transient and 4 permanent neurological deficits occurred. 33 patients had no post-operative complications at all and 25 patients had as only complication, transient arrhythmia. Follow-up revealed a 5-year survival rate of 83% and a cardiac event-free survival of 70%, without neurological events. We therefore conclude that simultaneous carotid TEA and cardiac surgery can be performed using controlled hypothermic cardiopulmonary bypass (26 degrees C), in experienced hands, with an acceptable mortality (5.4%) and low morbidity. Carotid TEA combined with two or more cardiac procedures has the highest mortality and morbidity and should be avoided.