The cost of simultaneous surgical standby for percutaneous transluminal coronary angioplasty.

From November, 1980, to May 1985, 699 patients have undergone percutaneous transluminal coronary angioplasty of 784 lesions at our institutions. Simultaneous surgical standby was available on all cases. One hundred twenty-four patients (18%) underwent immediate myocardial revascularization; 45 (6%) were operated on because the lesion could not be dilated. Seventy-nine patients (11%) underwent immediate operation for an acute complication of angioplasty: coronary occlusion in 45, dissection in 29, coronary perforation in three, and atrial perforation in one. Fourteen patients (18%) required cardiopulmonary resuscitation en route to the operating room, and 10 patients (20%) had insertion of an intra-aortic balloon pump in the cardiac catheterization laboratory. The average time from complication to reperfusion was 87 minutes, ranging from 40 to 165 minutes. An average of 2.0 grafts per patient (ranging from one to five grafts per patient) were performed. Of those 79 patients who underwent operation for an acute complication, one died (1.3%), 31 patients (39%) had a myocardial infarction according to enzyme criteria (creatine kinase-myocardial band greater than 40 IU), and 17 patients (22%) had new Q waves on the electrocardiogram. Good results are related to minimizing the time the myocardium is ischemic. No patient in whom reperfusion was begun in less than 75 minutes had a Q wave infarction or a creatine kinase-myocardial band level greater than 40 IU. Simultaneous surgical standby is the only method allowing immediate access to surgical facilities. A standby team of eight persons and equipment were immediately available for emergency bypass grafting for an average of 3.6 hours (range 1.3 to 5.4 hours per angioplasty attempt). The patient charges for this simultaneous standby were $632.00 per angioplasty attempt, or $442,278.00 for the entire series. The actual cost of the standby was over $1,700.00 per attempt totaling $1,188,843.00 for the 699 patients. This underestimation of the cost of surgical standby has occurred in other series, because little mention has been made of this cost in the published reports on the cost effectiveness of angioplasty. In terms of time demands, over 2,500 hours were spent by surgeons standing by for the 699 attempts. Simultaneous surgical standby is the most effective means of limiting the time the myocardium is ischemic after an angioplasty complication. However, this method is costly, necessitating more of a financial and time commitment than generally anticipated. Future studies of the cost effectiveness of angioplasty should include the cost of surgical standby with accurate per-patient cost accountability.

Combined valvular and coronary artery surgery.

Between July 1, 1971, and March 1, 1975, 45 patients underwent combined valvular and coronary artery operation. Aortic valve disease was present in 30 patients, mitral valve disease in 13, aortic and mitral valve disease in 1, and tricuspid valve disease in 1. The average age was 57 years. Seventeen patients were in New York Heart Association Functional Class IV. Seventeen patients had had a previous myocardial infarction. Significant coronary artery disease was an unexpected finding at the time of coronary angiography in 14 patients. The average number of grafts inserted was 2.5 per patient. The grafts were placed prior to valve replacement, and periods of myocardial ischemia were kept at a minimum by maintaining coronary perfusion throughout the operation. Operative mortality was 16%; late mortality was 8%. Perioperative myocardial infarction occurred in 2 patients.

Twenty-year follow-up of saphenous vein aortocoronary artery bypass grafting.

The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Forty-eight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, 10-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant relationships between the length of survival and sex, the number of grafts received, or the presence of left main stenosis. Survival was inversely related to age at initial operation (p = 0.046) as well as initial left ventricular end-diastolic pressure (p = 0.033). Survival positively correlated with the occurrence of triple-vessel disease (p = 0.031) and the presence of diffuse disease (p = 0.0077).(ABSTRACT TRUNCATED AT 250 WORDS)

Sternotomy infection: poor prediction by acute phase response and delayed hypersensitivity.

Two hundred twenty-one consecutive adult cardiac surgical patients were examined prospectively for nutritional protein state, acute phase protein response, and delayed hypersensitivity reaction in an attempt to identify patients at high risk for the development of sternal wound infection, which occurred in 6 patients (2.7%). There was no significant correlation between preoperative nutritional protein concentrations (retinol-binding protein, prealbumin, and transferrin) and acute phase protein levels (C-reactive protein, alpha 1-acid glycoprotein, and complements B and C3), nor a statistically significant relationship between nutritional state or acute phase protein response and the development of sternal infection. Preoperative complement C3 levels were elevated, however, in 80.0% of those in whom sternal infections developed compared with 30.6% of those with well-healed wounds. Similarly, postoperative concentrations of alpha 1-acid glycoprotein were elevated in 80.0% of those in whom sternal infections developed compared with 28.6% of those with well-healed wounds. There was no correlation between delayed hypersensitivity and the risk of sternal infection, nor between preoperative nutritional protein and acute phase protein values. Seventy-three percent of patients were anergic on postoperative day 2. Stepwise logistic regression showed that age, body weight, preoperative intensive care unit stay, repeat median sternotomy, internal mammary artery grafting, postoperative hemorrhage, and postoperative cardiac arrest correlated with the development of sternal infection, whereas transfusion requirement, reexploration for bleeding, and the operation performed did not. We conclude that routine delayed hypersensitivity testing is of no value in predicting high-risk cardiac surgical patients when the anergy battery is placed on the preoperative day. Although statistically insignificant, possibly due to the small number of patients in whom sternal infection developed in this study (type II error), a larger study might find preoperative complement C3 and post-operative alpha 1-acid glycoprotein levels to be predictive of patients at risk for the development of sternal wound infection. The final logistic model for the predicted risk 2%) of sternal wound infection is: PREDSWC = exp(EQ)/1 + exp(EQ) where EQ = (0.38 x age) + (0.24 x weight) + (5.42 x preop ICU) + (4.39 x redo) + (7.14 x IMA) + (4.49 x hemorrhage) + (8.81 x arrest) - 62.72, and where preop ICU, redo, hemorrhage, and arrest are defined as yes (1) or no (0), IMA-is defined as 0, 1, or 2, age is in years, and weight is in kilograms.

Coronary artery bypass surgery following thrombolytic therapy for acute coronary thrombosis.

One hundred thirty-six patients underwent thrombolytic therapy for acute evolving myocardial infarction from June, 1981, through December, 1982. Of these patients, 51 underwent coronary bypass procedures from two hours to 90 days (average, 16 days) following thrombolytic therapy. Six (12%) had single-vessel disease, 15 (29%) had double-vessel disease, and 30 (59%) had triple-vessel involvement. Ejection fraction values ranged from 21 to 60%. The average number of grafts performed per patient was 3.4. There were no operative deaths in this series. Postoperative hemorrhagic problems were minimal, and the incidences were no different from those for other coronary bypass patients. In follow-up ranging from 2 to 18 months, there was no recurrence of severe angina or other clinical evidence of saphenous graft occlusion in the thrombolysed vessels. Of the 45 patients eligible to return to work, 40 (89%) have done so. The data from this series suggest that surgical myocardial revascularization after intracoronary thrombolytic infusion for acute myocardial infarction can be performed safely and that complete recovery and a high return-to-work ratio can be anticipated.

Presentation of undiagnosed pheochromocytoma during coronary artery bypass surgery.

Hypertension and tachyarrhythmias arising during an operative procedure are rarely caused by an unsuspected pheochromocytoma. However, when this tumor becomes clinically manifest under general anesthesia during a procedure for an unrelated condition, the mortality is high. An unusual case of a patient who developed episodes of catastrophic hypertension and tachyarrhythmias while undergoing a coronary artery bypass procedure is described. The subject of undiagnosed pheochromocytoma becoming clinically manifest under general anesthesia is discussed with a pertinent review of the literature.

Surgery of left atrial myxomas. Report of eleven cases and review of the literature.

Eleven patients with left atrial myxoma in a ten-year period were reviewed. They ranged from 16 to 69 years old. Eight patients were female. All tumors were located in the left atrium; one patient had multiple tumors. The main clinical presentation was congestive heart failure seen in eight patients. Ten patients had a correct pre-operative diagnosis. Echocardiography confirmed the diagnosis in seven patients, angiocardiography in two and cardiac catheterization in one. All tumors were successfully removed with the aid of cardiopulmonary bypass and using a right atriotomy and trans-septal approach. Two patients underwent concomitant saphenous vein aortocoronary bypass. There were no operative deaths. Excision of the tumor resulted in marked symptomatic improvement. There have been no recurrences. A review of the pertinent literature is presented.

The assessment of operative results in congenital heart disease by intraoperative indicator-dilution curves.

In 260 patients with intracardiac shunts, indicator-dilution curves were recorded immediately after corrective operations. In every patient, the effectiveness of the repair was also determined at late postoperative cardiac catheterization or necropsy. In 248 patient (96 per cent) the presence or absence of a shunt, determined from the intraoperative curves, was confirmed by the findings at post-operative study. The intraoperative curves were normal in 213 patients, 209 of whom had no residual communication at late evaluation; in four patients, the studies indicated initial complete correction followed by recurrence of the shunt. Abnormal intraoperative curves were recorded in 47 patients, eight of whom died. In 17 of the 39 surviving patients, postoperative catheterization revealed persistent residual shunts comparable in magnitude to those present before operation. Fourteen patients had residual shunts that did not necessitate reoperation, and in eight patients, shunts present at the conclusion of the operation were shown to close in the postoperative period. The study indicates that the recording of intraoperative indicator-dilution curves provides a reliable objective method for evaluating the effectiveness of operation in patients with circulatory shunts. If normal curves are recorded, no residual shunt may be expected in 98 per cent of patients, and postoperative catheterization may be unnecessary unless other hemodynamic data are required. If abnormal intraoperative curves are recorded, however, postoperative study is mandatory, since the shunt will persist in 80 per cent of patients, in many of whom a second operation will be indicated.