Coronary artery bypass grafting in patients with ejection fractions below forty percent. Early and late results in 466 patients.

The outcome of patients undergoing coronary artery bypass grafting with preoperative ejection fractions below 40% was evaluated to determine if a specific level of ventricular dysfunction resulted in unacceptably poor short-term or long-term survival rates. Left ventricular ejection fractions were segregated into groups of five percentage points each starting from 35% to 39% and progressing down to 10% to 14%. In evaluating the six ejection fraction groups between 10% and 39%, we found no significant differences among them with regard to previous myocardial infarctions, left ventricular end-diastolic pressure (LVEDP), age, preoperative New York Heart Association (NYHA) class, or number of vessels bypassed. Eighty-four percent were men and 16% women. From 1976 through 1982, 466 patients were distributed among these groups, all having ejection fractions below 40% (mean 30% +/- 3% SEM). There were significant differences (p = 0.001) in both the hospital and long-term survival (36 months) of patients with preoperative ejection fractions from 20% to 39% (425 patients) as compared to those with preoperative ejection fractions from 10% to 19% (41 patients). Hospital survival rate was 89% for patients with ejection fractions from 20% to 39% but only 63% for patients with ejection fractions below 20%. Similarly, at 3 years, patients with ejection fractions of 20% to 39% had an average survival rate of 60% as compared to an average survival rate of 15% for those with ejection fractions below 20%. Neither the preoperative LVEDP nor the intraoperative ischemic arrest time significantly predicted survival. In all survivors, NYHA class decreased from an average of 3.00 to 1.25 in surviving patients following bypass at a mean follow-up of 29 +/- 5 months. It is concluded that ejection fraction is an excellent predictor of short-term and long-term survival following coronary artery bypass grafting. Patients with ejection fractions of 10% to 19% have a significantly reduced short-term and long-term survival rate as compared to patients with ejection fractions of 20% or more.

Coronary angioplasty versus coronary bypass. Three-year follow-up of a matched series of 250 patients.

Two hundred fifty consecutive patients treated for one or two vessel coronary artery disease with either balloon angioplasty or surgical bypass were monitored for 3 years in a study designed to determine the comparative long-term effectiveness of each treatment. The 125 patients having angioplasty were matched with the 125 patients having bypass, so that both groups had a similar number of patients with single or double vessel disease. The two groups did not significantly differ in age, male:female ratio, New York Heart Association class, or risk factors. The ejection fraction was 54 +/- 11 in the angioplasty group and 49 +/- 12 mmHg in the surgical patients (p = 0.0031). Angioplasty was deemed initially successful in 88% (110/125), unsuccessful in 10% (12/125), and in 2% (3/125) the lesion could not be crossed. Emergency bypass was performed in 10% (12/125). Four of the 125 angioplasty patients (3%) died within 30 days. Coronary artery bypass grafting was successfully performed on the matched set of surgical patients with 99% (124/125) discharged well. There was one (1%, 1/125) surgical death. The average hospital stay per patient was 4.8 +/- 3.1 days for angioplasty and 12.1 +/- 4.2 days for bypass grafting (p = 0.0000). Three-year postprocedure follow-up was obtained on 96% (236) of the 245 patients discharged alive. A second angioplasty was required in 18%, and 11 angioplasty patients subsequently required surgical bypass. Overall, 19% (23/121) of the angioplasty patients ultimately required bypass. Four late deaths occurred in the angioplasty group, which brought the early and late mortality rates to 7% (8/121). There were two late surgical deaths, which brought the combined surgical mortality to 2.5% (3/120), p = 0.1263. Patient evaluation reveals that 63% (76/121) of the angioplasty group are alive and in New York Heart Association class I or II 3 years after one or two angioplasty procedures. This figure compares with 92% (110/120) of surgical patients alive and in the same two New York Heart Association classes (p = 0.0000).

Selective arterialization of the coronary venous system. Encouraging long-term flow evaluation utilizing radioactive microspheres.

The long-term effectiveness of a retrograde coronary venous bypass graft (CVBG) to an ischemic left ventricle was evaluated in 18 dogs. A saphenous vein was interposed between the aorta and left anterior descending (LAD) vein. The LAD vein was ligated cephalad to the CVBG to prevent an arteriovenous fistula. The LAD artery was ligated at its origin to create anterior wall ischemia. Operative graft flow averaged 53 ml. per minute. The 14 surviving dogs were catheterized 3 to 5 months later. Ten of the 14 CVBG's were patent angiographically. The chests were opened and graft flow now averaged 50 ml. per minute. 141Ce microspheres were injected into the left atrium to measure myocardial flow to the anterior wall. In the 10 dogs with patent grafts, transmural flow was 39 +/- 1 (S.E.M.) ml. per 100 Gm. of tissue per minute. The endocardial/epicardial flow ratio was 1.4/1, indicating that retrograde venous perfusion effectively delivered blood to the subendocardium. After ligation of the CVBG, microsphere measured flow dropped to 15 +/- 1 ml. per 100 Gm. per minute. In 15 control dogs, anterior wall flow was 100 +/- 3 ml. per 100 Gm. per minute, decreasing to 13 +/- 2 ml. 45 minutes after ligation of the LAD artery and vein. None of the eight control dogs with simple ligation of the LAD artery and vein survived more than 5 days. Histologic examination of the anterior wall of the left ventricle, the area served by the CVBG's for 3 to 5 months, disclosed no evidence of venous sclerosis or thrombosis and no evidence of interstitial edema or hemorrhage. Thus a CVBG permitted long-term survival in an otherwise nonviable anatomic preparation. Moreover, restoration of flow with a CVBG was effective because it perfused all layers of the myocardium, especially the subendocardium--the crucial layer of myocardial muscle.

Timing of coronary revascularization after acute myocardial infarction. Early and late results in patients revascularized within seven weeks.

Evidence of ischemia after acute myocardial infarction is a serious complication. If angiography reveals significant coronary artery disease, the precise timing of myocardial revascularization may be of critical importance. From 1978 through 1982, 174 patients underwent myocardial revascularization within 7 weeks of a documented myocardial infarction. The male:female ratio was 138:36, the average age was 58 +/- 1 (SEM) years; and the ejection fractions averaged 41% +/- 1%. Forty-four (25%) patients required preoperative intra-aortic balloon pump support, and an additional 18 (10%) required intra-aortic balloon pumping to be separated from cardiopulmonary bypass. An average of 2.9 +/- 0.1 vessels per patient were bypassed. The hospital mortality for these 174 patients was 16%. When mortalities were categorized according to the postinfarction week in which operation was performed, hospital mortality fell from 46% for those patients operated upon within 1 week of infarction to 6% for those patients operated upon 7 weeks after infarction. Of those patients operated upon within the first week after infarction, 23% were in cardiogenic shock and 62% required preoperative balloon pumping. Clearly the most critically ill patients were operated upon during the early postinfarction period. However, there was a marked difference in survival when patients in each of the seven weekly groups were classified according to ejection fraction. All patients with an ejection fraction greater than or equal to 50% (50 patients) operated upon at any time after infarction survived their hospital course, with only one late death. Conversely, among the 124 patients with an ejection fraction less than 50% operated upon during this 7 week interval, there were 27 (22%) hospital deaths. In this latter group, survival rates steadily improved if revascularization was performed at a time more remote from the infarction. The difference in early and late survival rates of patients operated upon with an ejection fraction greater than or equal to 50% compared to patients with an ejection fraction less than 50% is highly significant (p less than 0.001). We conclude that myocardial revascularization is safe at any time after myocardial infarction for those individuals with an ejection fraction greater than or equal to 50%. However, if the ejection fraction is less than 50%, then operation after myocardial infarction should be delayed at least 4 weeks.

Delayed cardiac tamponade associated with prophylactic anticoagulation in patients undergoing coronary bypass grafting. Early diagnosis with two-dimensional echocardiography.

Pericardial tamponade occurring late in the hospitalization of a patient who has undergone a heart operation can be life threatening. Recognition of this insidious, but treatable, complication is difficult. Three patients experienced delayed tamponade while receiving warfarin prophylactically following coronary arter bypass. Two-dimensional echocardiography was useful in recognizing the effusion (and thus aided the diagnosis of tamponade) in each patients. The question of whether prophylactic antiocagulatin should be employed for patients undergoing coronary artery bypass procedures is also considered in light of both the present experience and collected reports from the literature.

Isolated coronary artery bypass grafting in patients seventy years of age and older: early and late results.

Increasing longevity makes the consideration of coronary bypass common in elderly patients. Seventy-five patients 70 years of age or older undergoing coronary artery bypass grafting (CABG) for angina pectoris were compared to a control group of 75 patients under 70 years of age. The groups were matched for male:female ratio (46:29), previous infarction (28/75), unstable angina (27/75), and the requirement for preoperative intra-aortic balloon pumping (7/75). Patients under 70 years of age had an average preoperative New York Heart Association (NYHA) class of 3.0 +/- 0.6 (SEM) and an average left ventricular end-diastolic pressure of 15.5 +/- 0.8 mm Hg, compared to 3.3 +/- 0.6 and 12.9 +/- 1.1 mm Hg, respectively, for the older group. Average grafts per patient were 2.7 +/- 0.8 in the younger group and 2.8 +/- 0.1 in the older group. Overall operative mortality for patients under 70 was 4% (3/75) versus 12% (9/75) (p = 0.06) for patients 70 and older. The incidence of chronic stable angina was 2% (1/48) versus 6% (3/48) (p = 0.30). Perioperative infarctions occurred in 7% of those under 70 and 5% of those 70 or older (p = 0.54). Those under 70 averaged 13.8 +/- 0.6 postoperative hospital days versus 18.4 +/- 1.2 hospital days for the older group (p less than 0.05). Follow-up ranged from 2 to 94 months, averaging 22 months for patients under 70 and 24 months for those 70 or older. Late cardiac mortality rates were 4% (3/70) in the younger patients and 3% (2/66) in the older patients (p = 0.53). Current NYHA class was 1.3 +/- 0.7 for those under 70, with 9% reporting angina, and 1.4 +/- 0.7 for those who were 70 or older, with 6% reporting angina. CABG can be performed with acceptable risk in older patients and leads to encouraging symptomatic improvement and late survival.

Aortic valve replacement in the elderly. Encouraging postoperative clinical and hemodynamic results.

Seventy-three patients aged 60 and over and 277 patients under 60 years of age underwent isolated aortic valve replacement (AVR) for aortic stenosis, regurgitation, and mixed disease from 1966 through 1975. Cardiac catheterization was performed five to nine months following operation in 77% of these patients. Follow-up averaged 55 months per patient. The hospital mortality in the elderly group was 2.7%, compared to 5.8% in the younger group. The late cardiac mortality was 21% and 19%, respectively. There was significant improvement (P less than .001) in the left ventricular end-diastolic pressure, cardiac index, and functional class in each of the three disease groups in the younger as well as the elderly patients. More important, the magnitude of improvement in each of these variables in patients over and under 60 years of age was not significantly different. Increasing longevity will make cardiac operations more common in the older population. These findings indicate that AVR carries the same low risk and brings about a similar improvement in left ventricular pump function in patients older and younger than 60.

Selective retrograde coronary venous perfusion.

The theoretical concept of delivering oxygenated blood to an ischemic myocardium by way of the coronary venous system antedated by many decades the present widespread utilization of coronary artery bypass grafting. Diffuse arterial atherosclerosis has limited the effectiveness of coronary artery bypass grafting in about 15% of patients seen with significant angina pectoris. Consequently, there has been renewed interest in selectively reversing the flow in certain coronary veins through coronary venous bypass grafts. This collective review details the physiology and anatomy of the coronary venous system. It then discusses the early attempts to globally retroperfuse the entire coronary venous system through the coronary sinus. Finally, the current experimental and clinical attempts to selectively retroperfuse just one region of the coronary venous system are presented and reviewed.

Pulmonary inactivation of vasopressors following cardiac operations.

Vasoactive drugs were infused through catheters in the right atrium and then the left atrium of 34 patients who required either vasopressor or vasodilator support following cardiac operation to determine if the route of infusion affected the aortic blood concentration of these agents. Drugs were given through the right atrium for one hour and then the left atrium for an hour. Both central aortic and pulmonary arterial blood were assayed for drug concentrations, and hemodynamic measurements were made. Sixteen patients receiving dopamine hydrochloride through the left atrium had a 36 +/- 12% (+/- standard error of the mean) increase in aortic concentration of the drug (p less than 0.005) and a 37 +/- 14% increase in cardiac index (p less than 0.005) compared with administration through the right atrium. Seven patients receiving epinephrine showed a 59 +/- 21% increase in aortic concentration (p less than 0.05) and a 21 +/- 10% increase in cardiac index (p greater than 0.05, not significant). Eleven patients receiving sodium nitroprusside achieved a 99 +/- 25% increase in aortic concentration (p less than 0.005) and a 20 +/- 7% increase in cardiac index (p less than 0.05). In all instances, significantly higher central aortic blood concentrations were achieved during left atrial (LA) versus right atrial (RA) infusions. Changes in blood concentration of the drug between the pulmonary artery and the aorta during RA infusion suggest removal or inactivation of these drugs in the pulmonary vasculature.(ABSTRACT TRUNCATED AT 250 WORDS)

Atheroemboli complicating the pre- and postoperative course of aortocoronary bypass (the trash heart): case report with comment.

A fatal instance of myocardial atheroembolization is described. Analysis suggests two and perhaps three separate episodes of embolization: the first occurred spontaneously about 2 weeks before admission, the second occurred intraoperatively, and it is possible that a third occurred immediately postoperatively. Intraoperative manipulations were additive to the earlier episode of spontaneous embolization. The descriptive terminology, "trash heart," is suggested. Operative techniques to prevent embolization are discussed.

Fetal alcohol syndrome: report of case.

A report of a patient with fetal alcohol syndrome has been presented with a review of the syndrome and the literature. Although the patient was treated in the operating room, many patients with less severe medical involvement or less extensive dental needs can be treated as outpatients. Each case must be considered individually with the prime concern being the patient's safety. Such patients may have numerous emotional or physical problems that the dentist must recognize. These patients are at high risk for several types of heart defects, many of which will require consultation for bacterial endocarditis precautions. The major and minor anomalies associated with fetal alcohol syndrome have been outlined.

The incidence of mucogingival defects: report of case.

The term true mucogingival defects has been used to denote a complete absence of attached gingiva. This study attempted to establish how often true mucogingival defects occur in a random population sample. Of the 1,302 teeth studied, 13 teeth (1%) had a mucogingival defect, indicating that the true mucogingival defect is not a common occurrence.

Early emergent coronary bypass after failed angioplasty.

Emergency CABG for failed coronary angioplasty was required in 3.3 percent of 1,625 consecutive patients undergoing angioplasties. Twenty-six percent of the patients died in the perioperative period. Efforts must be concentrated on identifying PTCA failure prior to cardiogenic shock.

Early emergent coronary bypass after failed angioplasty.

Emergency CABG for failed coronary angioplasty was required in 3.3 percent of 1,625 consecutive patients undergoing angioplasties. Twenty-six percent of the patients died in the perioperative period. Efforts must be concentrated on identifying PTCA failure prior to cardiogenic shock.