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Biomedical subjects

O M Shapira

Publications and source records attributed to O M Shapira.

At least 19 recordsLinked to original sources
PubMed2001

Functional small-diameter neovessels created using endothelial progenitor cells expanded ex vivo.

Arterial conduits are increasingly preferred for surgical bypass because of inherent functional properties conferred by arterial endothelial cells, especially nitric oxide production in response to physiologic stimuli. Here we tested whether endothelial progenitor cells (EPCs) can replace arterial endothelial cells and promote patency in tissue-engineered small-diameter blood vessels (4 mm). We isolated EPCs from peripheral blood of sheep, expanded them ex vivo and then seeded them on decellularized porcine iliac vessels. EPC-seeded grafts remained patent for 130 days as a carotid interposition graft in sheep, whereas non-seeded grafts occluded within 15 days. The EPC-explanted grafts exhibited contractile activity and nitric-oxide-mediated vascular relaxation that were similar to native carotid arteries. These results indicate that EPCs can function similarly to arterial endothelial cells and thereby confer longer vascular-graft survival. Due to their unique properties, EPCs might have other general applications for tissue-engineered structures and in treating vascular diseases.

Animals↗
PubMed2001

Early discharge after coronary artery bypass graft surgery: are patients really going home earlier?

OBJECTIVE: This study was undertaken to determine whether early discharge after coronary artery bypass grafting allows patients to return home earlier or merely increases the use of outpatient nursing and inpatient rehabilitation services. METHODS: Patterns of discharge were analyzed in 407 patients undergoing bypass grafting in 1990, when there were no early extubations or fast track protocols, and compared with 379 patients in 1998, when these protocols were used. RESULTS: Patients in 1998 had a higher prevalence of class IV angina (35.3% vs 22.8%; P =.006), urgent/emergency surgery (58.3% vs 44.9%; P =.015), and lower ejection fractions (48.9% +/- 16.4% vs 52.9% +/- 13.5%; P =.0002). Despite these increased risk factors, 1998 patients spent less time receiving ventilatory support (10.2 +/- 9.2 vs 26.7 +/- 15.7 hours; P <.001) and had a shorter length of stay (5.4 +/- 2.5 vs 9.2 +/- 4.3 days; P <.001). However, fewer 1998 patients were discharged home (56.7% vs 97.0%; P <.0001). A higher percentage of 1998 patients (43.3% vs 2.9%; P <.00001) were discharged to extended care facilities where their average length of stay was 10.6 +/- 15.1 days. Readmission to the Boston Medical Center was also more common in 1998 patients (5.3% vs 0.5%; P <.0001). CONCLUSIONS: Early extubation and fast track protocols have resulted in earlier discharge from acute care facilities. However, the anticipated earlier return to home has been offset by the increased use of outpatient nursing services, discharges to extended care facilities, and hospital readmissions.

Coronary Artery Bypass↗
PubMed2000

Nitroglycerin is preferable to diltiazem for prevention of coronary bypass conduit spasm.

BACKGROUND: Diltiazem is widely used to prevent radial artery spasm after coronary bypass grafting (CABG). However, recent in vitro and in vivo studies have shown that nitroglycerin is a superior conduit vasodilator compared to diltiazem. A clinical comparison of these agents in patients undergoing CABG has not been previously performed. METHODS: One hundred sixty-one consecutive patients undergoing isolated CABG with the radial artery were prospectively randomized to 24-hour intravenous infusion of nitroglycerin or diltiazem followed by 6-month treatment with a daily dose of isosorbide mononitrate (n = 84) or diltiazem CD (n = 77). Analyses were performed on "intention-to-treat" basis. RESULTS: Crossovers because of low cardiac output, complete heart block, or sinus bradycardia occurred in 5 patients in the diltiazem group and none in the nitroglycerin group (p = 0.05). Operative mortality (nitroglycerin, 1.2% versus diltiazem, 1.3%), major morbidity (14% versus 16%), perioperative myocardial infarction (1.2% versus 0%), peak serum creatinine phosphokinase MB fraction levels (27 versus 21 U), intensive care unit stay (34+/-19 versus 38+/-30 hours) and total hospital length of stay (4.7+/-1.4 versus 4.7+/-1.3 days) were similar (p = not significant for all). Cardiac pacing was required more often in the diltiazem group (28% versus 13%, p = 0.01). Follow-up longer than 2 months was available in 145 patients (90%). Follow-up mortality (nitroglycerin, 1.2%; diltiazem, 1.3%), myocardial infarction (6%, versus 5%), and reintervention (8% versus 6%) rates and average angina class (1.3+/-0.7 versus 1.1+/-0.4) were similar (p = not significant for all). Thallium stress test obtained in 117 patients showed abnormal perfusion in the radial artery territory in only 4 patients (3%), 2 in each group (p = not significant). Treatment with diltiazem was more costly ($16,340 versus $1,096). CONCLUSIONS: Nitroglycerin is preferable to diltiazem for prevention of conduit spasm. Nitroglycerin is safe, effective, better tolerated, and less costly than diltiazem, and therefore, should be the agent of choice.

Coronary Artery Bypass↗
PubMed1999

Enhanced nitric oxide-mediated vascular relaxation in radial artery compared with internal mammary artery or saphenous vein.

BACKGROUND: The superior long-term patency of internal mammary artery coronary bypass grafts compared with venous grafts has been attributed in part to increased endothelium-derived nitric oxide (. NO) production. Interest in the radial artery as an alternative bypass conduit has recently been revived; however, its biological characteristics remain incompletely defined. The purpose of this study was to compare the.NO-mediated vasomotor properties of the radial artery to those of the internal mammary artery and saphenous vein. METHODS AND RESULTS: Matched segments of radial artery, internal mammary artery, and saphenous vein (n=24 patients) were examined by use of organ-chamber methodology. Endothelium-dependent and -independent vasomotor responses were assessed by dose-response curves to acetylcholine, N(G)-nitro-L-arginine methyl ester (L-NAME), 8-bromo-cyclic 3',5'-guanosine monophosphate (8-bromo-cGMP), and nitroglycerin. Maximum.NO-mediated radial artery relaxation in response to acetylcholine (86+/-10%) was significantly greater than internal mammary artery (56+/-9%) or saphenous vein (11+/-5%, both P<0.0001). Similarly, acetylcholine-stimulated cGMP accumulation in radial artery (9.1+/-1.7 pmol/mg protein) was also greater than internal mammary artery (6.2+/-0.3 pmol/mg protein) or saphenous vein (1.4+/-0.2 pmol/mg protein, both P<0.05). Estimated basal endothelial.NO production, assayed as the percent maximum contraction in response to L-NAME, was greater in radial artery (39+/-5%) than internal mammary artery (23+/-6%) or saphenous vein (5+/-2%, both P<0.05). Maximum relaxation of all vessels to nitroglycerin was similar, although the sensitivity of radial artery to nitroglycerin was greater (EC(50)=33+/-7 nmol/L) than the internal mammary artery (203+/-32 nmol/L) or saphenous vein (97+/-12 nmol/L, both P<0.05). Vascular cGMP in response to 0.1 micromol/L nitroglycerin was significantly higher in the radial artery (8.3+/-1. 4 pmol/mg protein) compared with the internal mammary artery (3. 5+/-1.3 pmol/mg protein) or saphenous vein (1.4+/-0.3 pmol/mg protein, both P<0.0001). Relaxation to 8-bromo-cGMP was identical for all 3 conduits. CONCLUSIONS: These data indicate that. NO-dependent relaxation of radial artery is greater than that of internal mammary artery or saphenous vein. This difference is related to endothelial production of.NO and/or vessel sensitivity to. NO. Such favorable physiological characteristics of radial artery could conceivably contribute to improved long-term patency of this conduit compared with saphenous vein.

Adult↗
PubMed1999

Prolongation of rat skin and cardiac allograft survival by low molecular weight heparin.

BACKGROUND: We have previously reported that very low doses of low molecular weight heparin compounds (LMWH) inhibit a variety of T-cell-mediated reactions by down-regulation of TNF-alpha production. This study tested the efficacy of LMWH in organ transplantation. METHODS: Skin and heterotopic heart transplantations were performed between recipient Wistar rats and donor BN rats. Two doses of LMWH were given sc, 1 and 20 micrograms, each in three protocols, with day of grafting as Day 0: (A) Daily: -1, 0, 1 ellipsis, (B) Late Weekly: -1, 6, 13 ellipsis, and (C) Early Weekly: -7, 0, 7 ellipsis. Doses and schedules were selected based on efficacy in autoimmune models. Skin graft rejection was defined by complete separation of the graft, and heart transplant rejection was defined as cessation of heartbeat. RESULTS: Treatment with 1 microgram (26.8 +/- 2.0 days) and 20 micrograms (24.5 +/- 2.3 days) of LMWH using the Early Weekly protocol significantly prolonged skin allograft survival compared to controls (17.8 +/- 4.4 days), P < 0.001 for both, whereas other protocols did not. Compared to controls (8.3 +/- 1.4 days), treatment with both 1 and 20 micrograms of LMWH using all three protocols significantly prolonged cardiac allograft survival. The efficacy, however, varied considerably. Increase in graft survival ranged from 18% (1 microgram, Daily, 9.8 +/- 0.7 days, P = 0.02) to more than twofold (20 micrograms, Early Weekly, 20.8 +/- 5.5 days, P < 0.001) according to the dose and schedule of LMWH. CONCLUSIONS: Treatment with very low doses of nonanticoagulant LMWH preparations having anti-TNF-alpha activity significantly prolongs rat skin and cardiac allograft survival in a dose- and schedule-dependent manner.

Animals↗
PubMed1999

Effect of gender on postoperative outcomes and hospital stays after coronary artery bypass grafting.

BACKGROUND: Compared to men, women undergoing coronary artery bypass grafting appear to have a higher morbidity and mortality, particularly in the perioperative period. This study was designed to answer the questions of whether such differences in clinical outcomes between men and women still exist with improvements in surgical techniques and determine whether it is gender or associated comorbid conditions in women that lead to higher morbidity. METHODS: An analysis of a single center's contemporary experience (1994 to 1997) of 1,743 consecutive patients undergoing primary coronary artery bypass grafting was performed. Only reoperations were excluded. Data were collected prospectively and presented as mean +/- standard deviation (p<0.05). RESULTS: Women represented 30.0% of patients. Compared with men, women were older (68.4 versus 63.8 years; p<0.05), and had more urgent surgical interventions (70.0% versus 56.7%; p<0.05), a higher incidence of diabetes (42.1% versus 26.7%; p<0.05), hypertension (82.0% versus 73.9%; p<0.05), lower body surface area (1.73+/-0.18 m2 versus 2.03+/-0.19 m2; p<0.05), and hematocrit (31.7%+/-3.9% versus 36.2%+/-3.9%; p<0.05). Ejection fraction, incidence of previous myocardial infarction, chronic obstructive pulmonary disease, left main (LM) disease, renal insufficiency, extent of coronary disease, and preoperative intraaortic balloon pump were similar. Women received fewer arterial grafts (91.0% versus 95.5%; p<0.05) and distal anastomoses (3.31+/-0.88 versus 3.49+/-0.94 p<0.05). Despite these differences, there were no statistical differences in the incidence of postoperative death (1.5% versus 1.0%), myocardial infarction (0.6% versus 0.6%), or cerebrovascular accident/transient ischemic attack (1.1% versus 0.4%) between men and women. Women had a higher inotropic support (10.2% versus 4.4%; p<0.05) and longer hospital stays (7.3+/-5.7 days versus 6.3+/-4.2 days; p<0.05). Using multivariate analysis, female gender was not an independent predictor of death or postoperative complications but was a predictor of length of hospital stay, use of arterial grafts, and extent of coronary revascularization. CONCLUSIONS: After accounting for differences in their risk variables, the incidences of death, perioperative myocardial infarction and cerebrovascular accident/ transient ischemic attack after coronary artery bypass grafting in women and men were not statistically significant. Perioperative complications are related to comorbid risk factors but not to female gender itself. Further studies are warranted.

Age Factors↗
PubMed1999

Improved clinical outcomes after operation of the proximal aorta: a 10-year experience.

BACKGROUND: This study evaluated the impact of recent advances (particularly noninvasive diagnosis, retrograde cerebral perfusion, heparin-bonded circuits, and use of collagen-impregnated grafts and antifibrinolytic agents) on clinical outcomes of patients undergoing proximal aortic operations. METHODS: One hundred eight consecutive patients undergoing 111 proximal aortic operations over 10 years were studied. The cohort was divided into two groups: early, 1987 to 1993 and late, 1994 to 1997. RESULTS: Baseline patients profiles, indications for operation (aneurysm, 66 patients; dissection, 45 patients), priority of the operation, and surgical procedures were comparable for both groups. Mortality and morbidity for the entire cohort were 13.5% (15 of 111) and 66% (73 of 111), respectively. Compared with the early group, the late group was characterized by significantly higher use of noninvasive diagnostic modalities (69% versus 10%), exclusive use of heparin-bonded circuits and collagen-impregnated grafts (100% versus 0% for both), use of antifibrinolytic agents (79% versus 8%), and the introduction of retrograde cerebral perfusion (43% versus 0%) (p<0.00001 for all). These changes in practice were associated with a substantial decrease in operative mortality (26% [13 of 49] versus 3% [2 of 62], p = 0.001), overall morbidity (77% [38 of 49] versus 56% [35 of 62], p = 0.02), blood transfusions (55.6+/-48 donor units versus 29.3+/-35 donor units, p = 0.003), and a shorter hospital stay (21.6+/-31 days versus 12.1+/-15 days, p = 0.07). Average long-term follow-up for 99% (107 of 108) of patients was 29.6+/-30 months (1 to 120 months). Ten-year actuarial survival was 57.3%+/-8% with 93% being in New York Heart Association functional class I or II. CONCLUSIONS: Recent advances, particularly noninvasive diagnosis and improved operative management, have led to a substantial reduction in mortality and morbidity after proximal aortic operation. Improved short- and long-term outcomes were achieved both in acute dissection and aneurysm procedures, although patients remain at risk for long-term distal aortic complications.

Adult↗
PubMed1999

Favorable impact of stents after emergent coronary artery bypass for failed angioplasty.

BACKGROUND: This study was undertaken to determine the impact of the use and availability of coronary stents on outcomes in patients requiring emergent coronary artery bypass graft (CABG) surgery following a failed percutaneous transluminal coronary angioplasty (PTCA). METHODS: Patients were divided into two groups based on the year of their CABG for a failed PTCA and the availability of stents: group 1, 1992 to 1994, stents not available (n = 34); and group 2, 1995 to 1997, stents available (n = 26). RESULTS: CABG patients in the group where stents were not available were more likely to have had an abrupt coronary occlusion (26 of 34 versus 3 of 26; p < 0.0001) and less likely to have had a dissection (8 of 34 versus 23 of 26; p < 0.0001) as their indication for emergent CABG. Patients in the stent era had a lower incidence of perioperative myocardial infarction (5 of 26 versus 17 of 34; p < 0.01) and a decreased mortality rate (0 of 26 versus 6 of 34; p < 0.03). In the 9 patients where stents were employed, patency of the lumen was restored in 8 patients and there was only 1 myocardial infarction. CONCLUSIONS: Stents have had a favorable impact on patients requiring an emergent CABG following a failed PTCA.

Aged↗
PubMed1999

Papillary fibroelastoma: increasing recognition of a surgical disease.

Papillary fibroelastomas are uncommon benign tumors usually involving the heart valves, which historically have been diagnosed at autopsy. With the advent of echocardiography, however, the number of patients diagnosed in life has increased. Papillary fibroelastomas represent a surgically treatable cause of cerebrovascular and cardiovascular ischemia and infarction making their identification clinically important. We report three unusual cases of papillary fibroelastoma; two patients presenting with symptoms of cerebrovascular ischemia and one presenting with myocardial infarction. We also present a comprehensive review of the literature and provide a compilation of all case reports to date.

Adult↗
PubMed1999

Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy.

BACKGROUND: Coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) has been associated with increased morbidity and mortality. We sought to evaluate the impact of recent advances in operative and perioperative management on outcomes after CE. METHODS: One hundred fifty-one consecutive patients undergoing first-time CABG with CE between 1991 and 1997 were compared with a concurrent group of 757 patients undergoing CABG without CE (Control). RESULTS: Age, gender, left ventricular ejection fraction, percent nonelective were similar in both groups. Compared with control, the CE group had a higher incidence of hypertension (80% versus 71%, p = 0.02), diabetes (42% versus 32%, p = 0.01), prior myocardial infarction (MI) (68% versus 59%, p = 0.05), peripheral vascular disease (36% versus 16%, p < 0.001), renal failure (15% versus 4%, p < 0.001), and three-vessel coronary disease (81% versus 70%, p = 0.007), resulting in higher Society of Thoracic Surgeons database predicted mortality (4.9+/-5.9% versus 3.9+/-4.6%, p = 0.05). Despite the higher risk profile of the CE group, hospital mortality (CE 2.0%, Control 1.2%) and the incidence of major complications such as cerebrovascular accident (CVA) (0.7% versus 1.5%), major respiratory complications (8% versus 5%), and postoperative MI (3% versus 1.4%) were similar between the groups (all p = NS). In a multiple logistic regression analysis, prolonged cardiopulmonary bypass time was an independent predictor of postoperative MI (odds ratio 1.2, CI 1.05 to 1.39, p < 0.01) and the use of heparin-bonded cardiopulmonary bypass circuits of reduced MI rate (odds ratio 0.25, CI 0.08 to 0.76, p < 0.01). Mean follow-up for 94% of patients was 30+/-19 months (range 1 to 83 months). Five-year survival after CE was 70+/-5%, with 96% of patients in Canadian Cardiovascular Society class I/II. CONCLUSIONS: In a contemporary series of carefully selected patients, mortality and major complications after CE are now similar to CABG without CE. CE itself is not an independent predictor of postoperative MI. Functional class of hospital survivors is excellent.

Aged↗
PubMed1999

Nitroglycerin is superior to diltiazem as a coronary bypass conduit vasodilator.

BACKGROUND: Recent reports of improved radial artery patency have been attributed, in part, to routine use of diltiazem to prevent vasospasm. However, diltiazem is costly, and its use may be associated with negative inotropic and chronotropic side effects. This study compares the vasodilatory properties of diltiazem to those of nitroglycerin. METHODS: In vitro, with the use of organ chambers, the vasodilatory properties of diltiazem and nitroglycerin were compared in matched segments of radial artery, internal thoracic artery, and saphenous vein that were harvested from the same patients (n = 11). The vasodilatory response of the radial artery to intravenous diltiazem or nitroglycerin was compared in vivo (n = 10) with the use of ultrasonographic measurements of radial artery diameter. RESULTS: The maximum relaxation of radial artery (100% +/- 4%), internal thoracic artery (96% +/- 4%), and saphenous vein (100% +/- 3%) to nitroglycerin were significantly greater than the response to diltiazem (33% +/- 6%, 22% +/- 7%, and 34% +/- 5%, respectively; P <.001). The thromboxane mimetic, U46619, induced radial artery spasm with a median effective concentration of 3.7 +/- 0.8 nmol/L. Physiologic concentrations of nitroglycerin (0.1+/- micromol/L) significantly inhibited the radial artery response to U46619 (median effective concentration, 6.2 +/- 1.1 nmol/L; P =.046), whereas diltiazem (1 micromol/L) did not (median effective concentration, 3.7 +/- 0.8 nmol/L; P =.64). In vivo, nitroglycerin increased radial artery diameter 22% +/- 3%, which was significantly greater than diltiazem (3% +/- 0.5%; P =.001). CONCLUSION: Nitroglycerin is a superior conduit vasodilator and is more effective in preventing graft spasm than diltiazem. Nitroglycerin should be strongly considered as the drug of choice to prevent conduit spasm after coronary bypass grafting.

Adult↗
PubMed1999

Heparin-bonded circuit with low systemic anticoagulation in a patient with heparin-induced thrombocytopenia: a case report.

Heparin-induced thrombocytopenia (HIT) in patients undergoing open heart surgery has been reported with increasing frequency. Several strategies have been suggested to approach this difficult problem. However, the syndrome is still associated with significant morbidity and mortality. We describe an 82-year-old male with HIT who underwent coronary artery bypass grafting utilizing a heparin-bonded cardiopulmonary bypass circuit with very low systemic anticoagulation. Only one unit of packed red blood cells was transfused. The patient recovered uneventfully. This strategy is safe and effective, and, therefore, should be considered in patients with HIT.

Aged↗
PubMed1998

Effect of anticoagulation protocol on outcome in patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits.

BACKGROUND: We have demonstrated that the use of heparin-bonded cardiopulmonary bypass circuits (HBCs) combined with a lower anticoagulation protocol as an adjunct to an integrated blood conservation strategy decreases the incidence and magnitude of homologous transfusion and improves clinical outcome in patients undergoing primary coronary artery bypass grafting. It is not known whether it is the lower anticoagulation protocol that influences outcome in patients treated with HBCs. Furthermore, the thrombogenic risk of using lower anticoagulation with HBCs still is debated. METHODS: To answer these questions, a prospective randomized study was conducted in which 244 patients undergoing primary coronary artery bypass grafting were treated with HBCs and randomized to undergo either a full (activated clotting time, > 450 seconds) or a lower (activated clotting time, > 250 seconds) anticoagulation protocol. In addition to clinical outcome, levels of thrombin generation markers during and after cardiopulmonary bypass were assessed in a consecutive subset of 58 patients (full anticoagulation profile = 28, lower anticoagulation profile = 30) by measuring thrombin-antithrombin complexes and prothrombin fragment 1.2. Levels of these markers also were correlated with the activated clotting time during cardiopulmonary bypass. RESULTS: Preoperative and intraoperative risk profiles and other characteristics were similar in both groups, with more than 60% of patients undergoing nonelective operation. Compared with the full anticoagulation protocol group, patients in the lower anticoagulation protocol group were less likely to require blood products (24.2% versus 35.8%, respectively; p = 0.047) and received substantially fewer homologous donor units (0.50 +/- 0.92 versus 1.08 +/- 2.10 U, respectively; p = 0.005). Clinical outcomes were uniformly outstanding (but similar) in both treatment groups, with a modest reduction in the length of the hospital stay in the lower anticoagulation protocol group (5.26 +/- 1.23 versus 5.63 +/- 1.73 days, respectively; p = 0.05). The use of HBCs with a lower anticoagulation protocol was not associated with any adverse clinical events. Thrombin generation increased during cardiopulmonary bypass in both treatment groups, but was unrelated to the anticoagulation protocol or the activated clotting time (r2 = 0.03). No differences between the full and lower anticoagulation protocol groups were noted in the number of microemboli detected by transcranial Doppler analyses during cardiopulmonary bypass (n = 40) or in the postoperative neurologic and neuropsychologic outcomes (n = 30). CONCLUSIONS: This study definitively demonstrates that, when used appropriately, patients who are treated with HBCs and a lower anticoagulation protocol have a lower incidence and magnitude of homologous transfusion and are not at any added risk for clinical, hematologic (thrombin-antithrombin complex and fragment 1.2 measurements), or microscopic (transcranial Doppler analyses) thromboembolic complications or for neurologic or neuropsychologic deficits.

Aged↗
PubMed1998

Reduction of allogeneic blood transfusions after open heart operations by lowering cardiopulmonary bypass prime volume.

BACKGROUND: Despite recent advances in blood conservation techniques, up to 30% to 80% of patients undergoing open heart operations require allogeneic blood transfusions. A prospective, randomized study was performed to test the effect of lowering cardiopulmonary bypass prime volume (as an additional component of an integrated blood conservation strategy) on clinical outcome and allogeneic blood transfusion. METHODS: One hundred fourteen patients undergoing open heart operations were randomized to either full prime (FP) volume (1,400 mL of Plasmalyte solution) or reduced prime (RP) volume (600 to 800 mL). The reduction of prime volume was achieved by slowly draining the cardiopulmonary bypass circuit into a cell-saving device before the initiation of bypass. Firm transfusion thresholds were observed. RESULTS: There were no significant differences between the groups with respect to baseline characteristics, body surface area, type and urgency of the procedures, perfusion technique, and hematologic profile. Mortality (FP, 1.7%; RP, 0%; p approximately 1.0) and overall morbidity (FP, 28.1%; RP, 22.8%; p = 0.53) were similar. However, transfusion requirements were significantly lower in the RP group: total donor exposure, 3.8 +/- 10.1 versus 1.0 +/- 2.4 units (p = 0.044); percentage of patients transfused, 54% (n = 31) versus 35% (n = 20) (p = 0.036). Twenty-four-hour chest tube drainage was similar: 455 +/- 223 mL for FP versus 472 +/- 173 mL for RP (p = 0.66). The lowest hematocrit on bypass was significantly higher in the RP group: 29.3% +/- 4% versus 26.3% +/- 5.3% (p = 0.009). CONCLUSIONS: Lowering cardiopulmonary bypass prime volume resulted in a significant decrease in allogeneic blood product use. Because postoperative 24-hour chest tube drainage was similar in both groups, and hematocrit during bypass was higher in the RP group, the reduction in allogeneic blood transfusions appears to be related to a decrease in prime-induced hemodilution. This technique is effective, simple, and safe. It therefore should be strongly considered for patients undergoing operations using normothermic or near-normothermic cardiopulmonary bypass who are at high risk for allogeneic blood transfusion.

Aged↗
PubMed1998

Comparison of risk profile and outcomes in patients undergoing surgical and catheter-based revascularization.

BACKGROUND: The effects of the randomized revascularization trials and improved strategies and techniques for coronary artery bypass graft (CABG) surgery and percutaneous transluminal catheter-based revascularization (PTCR) on current patient selection and clinical outcomes are unknown. METHODS: We evaluated a concurrent, contemporary (1995 to 1997), and consecutive group of patients undergoing CABG (n = 982) or PTCR (n = 939) in a single institution that participated in the Bypass Angioplasty Revascularization Investigation (BARI) trial. Results are presented as percent or mean +/- SD. Compared to PTCR, patients undergoing CABG were older (66.2+/-10.7 vs. 62.0+/-11.8 years, p<0.05) with a higher incidence of hypertension (73.3% vs. 52.4%, p<0.05), diabetes (32.5% vs. 23.1%, p<0.05), active smoking (67.8% vs. 27.2%, p<0.05), prior myocardial infarction (MI)(66.8% vs. 28.5%, p<0.05), peripheral vascular disease (19.8% vs. 7.7%, p<0.05), prior cerebrovascular accident (CVA)/transient ischemic attack (TIA) (6.4% vs. 2.8%, p<0.05), and a lower ejection fraction (48.7%+/-14.5% vs. 55.3%+/-11.7%, p<0.05). The presenting functional class and incidence of female gender were similar for both revascularization strategies. RESULTS: Compared to patients undergoing CABG, those undergoing PTCR were more likely to have single or two vessel coronary artery disease (88.6% vs. 23.1%, p<0.001) and had fewer vessels revascularized per patient (1.08+/-0.30 vs. 3.5+/-0.98, p<0.001). Outcomes were comparable for CABG and PTCR with a similar incidence of death (1.0% vs. 0.9%, NS), renal insufficiency (0.7% vs. 0.6%, NS), and CVA/TIA (0.9% vs. 0.3%, NS). Patients undergoing CABG had a higher incidence of pulmonary complications (5.2% vs. 1.0%, p<0.05), a lower incidence of periprocedural MI (1.1% vs. 4.1%, p<0.05) and major complication (5.9% vs. 9.4%, p<0.05), but longer hospital stays (6.5+/-5.1 vs. 3.1+/-2.6 days, p<0.05). CONCLUSIONS: Despite higher clinical and angiographic risk profiles in patients undergoing CABG, clinical results, morbidity, and mortality were comparable to those of PTCR. With evolving techniques, continued reevaluation of indications and outcomes are necessary.

Aged↗
PubMed1997

Repair of left ventricular aneurysm: long-term results of linear repair versus endoaneurysmorrhaphy.

BACKGROUND: Recently, endoaneurysomorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques. METHODS: Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair. RESULTS: The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 +/- 0.08 versus 0.30 +/- 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 +/- 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 +/- 0.64 versus 0.18 +/- 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair (p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 +/- 0.11 versus 0.27 +/- 0.11; p = 0.90), left ventricular volume (171.6 +/- 59.1 versus 169.9 +/- 54.4 mL; p = 0.94), and sphericity index (0.61 +/- 0.09 versus 0.61 +/- 0.12; p = 1.0). CONCLUSIONS: Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.

Case-Control Studies↗