Is gender an independent risk factor for coronary bypass grafting?

BACKGROUND: Postoperative mortality after coronary artery bypass grafting (CABG) surgery is traditionally considered to be influenced by gender. However, the data are conflicting and it is not clear whether gender is a true independent risk factor for death in this setting. We analyzed our database to determine whether gender is an independent risk factor for death after CABG. PATIENTS AND DESIGN: A retrospective analysis of 1 758 isolated first-time coronary artery bypass graft patients treated between 2003 and 2005 was conducted in the Department of Cardiothoracic Surgery of Rabin Medical Center, a major tertiary facility in Israel. RESULTS: The female patients had a distinctly different pre- and intraoperative profile compared with the male patients, and significantly higher postoperative mortality (p < 0.05). On a propensity scoring of 359 matched pairs, the risk factors for death were found to be severe left ventricular dysfunction, chronic obstructive pulmonary disease, and use of an intra-aortic balloon pump (p < 0.05). The addition of intraoperative data to the model yielded only cardiopulmonary bypass time and use of an intra-aortic balloon pump as risk factors for death (p < 0.05). Validation with the bootstrap technique revealed that strong predictors of death (> 50 % of the sample) were cardiopulmonary bypass time, use of an intra-aortic balloon pump, and, to a lesser extent, chronic obstructive pulmonary disease. Female gender was not found to be an independent risk factor for death after coronary artery bypass graft. CONCLUSIONS: Female gender is apparently not an independent risk factor for coronary artery bypass graft mortality in this patient group.

A one-way valved atrial septal patch: a new surgical technique and its clinical application.

Patients who undergo surgical repair of congenital heart defects, characterized by a hypoplastic right ventricle or high pulmonary vascular resistance, are at high risk for the development of postoperative right heart failure. This risk may discourage the surgical team from carrying out a biventricular or complete repair in such patients. To reduce the risk for right heart failure, we developed a one-way, valved, atrial septal patch to serve as an artificial one-way foramen ovale and tested it in an animal model. By permitting right-to-left shunt, this device decompresses the failing right ventricle and maintains systemic cardiac output. The device has been used in 15 patients divided into three different groups: group 1 (n = 8), patients with a hypoplastic right ventricle and pulmonic stenosis or atresia, seven of whom underwent a biventricular repair; group 2 (n = 5), patients with evidence of pulmonary disease after longstanding left-to-right shunt caused by a correctable atrial or ventricular septal defect, all of whom had a complete repair; group 3, two patients with acute right heart failure in whom the device was used as a last option of treatment to wean them from cardiopulmonary bypass. This article presents our data in regard to the use of the one-way, valved, atrial septal patch and the indications for its clinical use.

Metabolic effects of intramuscular and oral administration of ritodrine in pregnancy.

The metabolic effects of ritodrine, 80 mg/day, administered intramuscularly in the third trimester of pregnancy to 14 patients for 5 days and per os to 10 patients for 10 days were investigated. Each patient was considered at high risk for premature labor. Intravenous glucose tolerance and insulin, triglyceride, and electrolyte levels were assessed before and at the end of treatment with ritodrine. Intramuscularly or orally administered ritodrine in 10-mg doses 8 times a day did not influence carbohydrate homeostasis. Triglyceride levels fell significantly after intramuscular administration, whereas serum potassium levels increased during treatment. This study suggests that ritodrine administered intramuscularly or orally is metabolically safe in nondiabetic pregnant women.

Effective technique of sternum closure in high-risk patients.

A successful technique of closing the sternum in a selected group of poor-risk patients involves the combination of a mattress suture and a fixative single-wire suture, both of 0 stainless-steel monofilament. Our technique was used on 100 high-risk patients and compared with double control groups, one consisting of 200 normal-risk patients and the second of 100 high-risk patients. We found that the incidence of wound infections was reduced to 1% with our new technique compared with 3% and 1% in the control groups (the high- and normal-risk groups, respectively). There was neither dehiscence nor mediastinitis in the study group, compared with 1% and 0.5% incidences of these complications in the controls. Also, there was no mortality in the combined-closure group compared with mortality of 0.5% and 1% in the control groups. We believe that this closure effectively strengthens the complex of bone and wire, improving the stability of the chest by giving a correct axis to the sternum. It is also cost-effective and easy to perform and does not prolong operation time.

Management of major tracheal hemorrhage after repair of complex congenital heart defects.

Two patients with complex congenital heart defects (a 4-year-old with transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction and a 3 1/2-year-old with double-outlet right ventricle, subpulmonary stenosis, and complete atrio-ventricular septal defect) suffered multiple major hemorrhages from the tracheobronchial tree (28 and 7 bleeding events, respectively). Successful management included tracheostomy, sedation and paralysis, systemic hypotension, and systemic hypothermia for a period of seven days. Both patients survived.

Current surgical technique to repair Fallot's tetralogy with absent pulmonary valve syndrome.

The experience with surgical repair of Fallot's tetralogy and absent pulmonary valve syndrome is reviewed. Twenty-two patients aged 1 day to 8 years were treated between 1982 and 1989 using one surgical technique. This consisted of resection of the main pulmonary artery and large parts of the anterior wall of the right and left pulmonary artery. The ventricular septal defect was closed with a patch, and an aortic or pulmonary homograft (size, 8 to 24 mm) was interposed between the right ventricle and the pulmonary artery. Two of the 8 infants operated on died; there was one late death. All 14 older children survived the operation. All survivors are well up to 7 years follow-up (mean follow-up, 3.6 years). We recommend early treatment of infants; older children can be treated electively. The technique used in our series gives excellent results.

Histologic atrial myolysis is associated with atrial fibrillation after cardiac operation.

BACKGROUND: Postoperative atrial fibrillation after cardiac operation is common. Despite the identification of risk factors associated with postoperative atrial fibrillation, the pathophysiologic mechanisms remain unclear. Myolysis has been recently described to be associated with maintenance of atrial fibrillation in experimental animals. In this study, we attempted to identify histopathologic changes in atria that might predict the development of postoperative atrial fibrillation, and specifically address its association with myolysis. METHODS: Right appendicular atrial tissue was sampled before and after cardiopulmonary bypass from 60 patients in sinus rhythm who underwent elective coronary artery bypass grafting. RESULTS: Fifteen patients (25%) developed postoperative atrial fibrillation. Histopathologic abnormalities were found in most patients (52 of 60). However, only myolysis and lipofuscin levels were found to be an independent histologic finding associated with the development of postoperative atrial fibrillation. Electron microscopy showed that myolytic vacuoles were not membrane bound, and were associated with lipofuscin deposits. Neither mitochondrial pathology nor apoptosis was detected in the atria before or after operation. CONCLUSIONS: Abnormalities in biopsies before cardiopulmonary bypass can indicate the susceptibility to develop postoperative atrial fibrillation. This implies that the status of the atrium before cardiopulmonary bypass is a major determinant in the development of this common complication.

Surgical removal of stent entrapped in proximal left coronary artery system.

Coronary artery stents were developed to prevent acute coronary closure and reduce restenosis after coronary angioplasty. A well-recognized, although uncommon, complication of stent deployment is loss of control, resulting in the stent being inadvertently deployed in an undesirable location. This case study describes a patient who underwent stent insertion to the left anterior descending artery and had stent entrapment in the left anterior descending/left main coronary artery. The stent was surgically removed, preventing unnecessary bypass grafting to a normal circumflex artery.

Thromboxane production in human lung during cardiopulmonary bypass: beneficial effect of aspirin?

BACKGROUND: Increased systemic levels of thromboxane (Tx) during cardiopulmonary bypass (CPB) in humans have been reported. It is not known whether this reflects a general systemic response to the surgical procedure or an increased pulmonary production of Tx in response to ischemia and reperfusion. METHODS: Thromboxane B2 levels were measured in the right atrium and left atrium of 14 patients undergoing coronary artery bypass grafting for angina. Eight patients (group 1) were without aspirin for at least 15 days before operation, and 6 patients (group 2) were treated with aspirin (100 mg/day) for at least 1 month before operation. Levels of TxB2 were determined by enzyme immunoassay after lipid extraction and separation. RESULTS: Thromboxane B2 levels were elevated throughout CPB. In group 1, left atrial TxB2 levels were significantly higher (p < 0.05) than right atrial levels at all study points during CPB. After pulmonary reperfusion, TxB2 levels in both atria increased significantly (p < 0.02) compared with the levels before cross-clamping of the aorta, and there was an increasing gradient between the two atria (p < 0.05). Mean plasma TxB2 levels during CPB in group 2 were significantly reduced (p < 0.0001) in the right atrium (by 73%) and in the left atrium (by 69%) compared with levels in group 1. CONCLUSIONS: The rise in TxB2 levels in the left atrium after CPB in humans reflects production of Tx mainly in the lungs, most probably by ischemic pulmonary tissue and intravascular hematologic components. Aspirin markedly reduces Tx production during CPB, and it might play a major role in preventing pulmonary injury after operations with CPB in humans.

Potential preoperative markers for the risk of developing atrial fibrillation after cardiac surgery.

Postoperative atrial arrhythmias after cardiac surgical procedures are common, with a reported overall incidence of approximately 50%. The pathophysiological mechanisms responsible for atrial fibrillation after a cardiac procedure remain unclear, although several clinical studies published during the past decade have identified certain preoperative risk factors associated with postoperative atrial fibrillation. In this study, we attempted to identify the histopathological changes in atrial cardiomyocytes that might predict the development of atrial fibrillation during the postoperative period. Atrial tissue from 60 patients was sampled before and after a cardiopulmonary bypass. Fifteen patients (25%) developed postoperative atrial fibrillation. The only clinical independent risk factor for the development of postoperative atrial fibrillation was chronic obstructive pulmonary disease (COPD) (P = .037). Histologically, there were 3 findings in the atrial myocardium that were more common in patients who developed postoperative atrial fibrillation: (1) vacuolation size (P = .017), (2) vacuolation frequency (P = .0136), and (3) lipofuscin content (P = .013). The identification of these histological markers for the development of postoperative atrial fibrillation may contribute not only to our understanding of the underlying pathophysiology that leads to postoperative atrial fibrillation but also to a method of preventing this troublesome complication of cardiac surgery.

Repeated thrombolysis in multiple episodes of obstructive thrombosis in prosthetic heart valves: a report of three cases and review of the literature.

BACKGROUND AND AIM OF THE STUDY: Thrombolysis is an emerging method to open thrombosed prosthetic heart valves. However, its applicability and safety in multiple recurrent thrombotic episodes is unclear. METHODS: Among 16 patients with thrombosed prosthetic valves treated with thrombolysis during a 33-month period, three patients (one mitral and two tricuspid) experienced four episodes each, and these were treated with repeated thrombolytic therapy. Data on patient demographics, clinical presentation, diagnosis, treatment and outcome are presented. RESULTS: Thrombolysis was successful in 10/12 episodes (83%); there was delayed response in one episode (8%), and partial response in one episode (8%). There were no major complications. However, a fifth thrombotic episode occurred in two patients with tricuspid prostheses, mandating re-do surgery. CONCLUSION: Thrombolysis in re-thrombosed prosthetic heart valves is feasible, highly successful and safe, and may therefore be used judiciously in selected patients who could not, or would not, undergo redo surgery. A high recurrence rate in the tricuspid position may implicate earlier surgical intervention, which should be individualized.

Total cavopulmonary connection (TCPC) for complicated congenital heart malformations.

We reviewed our experience with 40 patients who had undergone total cavopulmonary connection (TCPC) during the past three years. Thirty-one patients had functional single ventricle; only 8 of these with tricuspid atresia, five patients had complex forms of double outlet right ventricle (DORV), and four complex A-V canal. Previous palliative procedures, mostly systemic-pulmonic shunts, were performed in 34 patients. Concomitant procedures were required in 18 patients, mainly reconstruction of distorted pulmonary arteries. A subgroup of 14 high risk patients, that did not fulfil the classical Fontan criteria, underwent 4 mm fenestration of the intra-atrial baffle. There were three (7.5%) early postoperative deaths which occurred in the higher risk group (fenestrated group). However, the remaining patients were all in functional class I or II. Total cavopulmonary connection provides reasonably good definitive palliation for patients with single ventricle physiology. Fenestration of the intra-atrial baffle increases the number of candidates suitable for the Fontan procedure, although the exact inclusion criteria for these patients has yet to be defined.

Musculoskeletal manifestations of Crohn's disease.

The prevalence of musculoskeletal system complaint and involvement in a group of 54 Crohn's disease patients, with a follow-up of 2 to 40 years, was studied and compared to that of a control group of patients with a similar distribution of sex and age. Twenty-four (44%) with Crohn's disease complained of arthralgia in various joints, but only 7.4% had objective findings compatible with joint pathology such as swelling, tenderness, and decreased range of motion. None of them had any serological or radiological evidences of joint damage. No significant correlation was found between patients' complaints/physical signs and age, sex, duration, or severity of Crohn's disease or mode of medical or surgical treatment. In the control group, 46% complained of arthralgia in various joint. The differences in the percentages of arthralgia between the two groups was not significant, although they differed in location of the affected joint. In the Crohn's disease group, a significantly higher proportion of knee, hip, and wrist involvement was observed, while backache was very common in the control group. It is suggested that arthritis in patients with Crohn's disease is an uncommon finding and that arthralgia is just as prevalent as in a matched control group. The pathogenesis of arthralgia in such a condition may be caused by soft tissue involvement.

Cardiac surgery in patients on chronic hemodialysis: short and long-term survival.

OBJECTIVE: Open-heart surgery carries a high risk for hemodialysis patients. This study focuses on the short and long-term outcomes of hemodialysis patients undergoing heart surgery. DESIGN: The study was carried out as a retrospective analysis in the Department of Cardiothoracic Surgery in a large university-affiliated hospital. PATIENTS: 115 hemodialysis patients underwent cardiac surgery in our department between 1 July 1996 and 31 July 2006. 67.5 % (77 patients) underwent isolated coronary artery bypass grafting (CABG), 13.2 % (15 patients) underwent isolated aortic valve replacement (AVR) and 20.2 % (23 patients) underwent mitral valve surgery or combined valve and coronary artery bypass grafting or multiple valve surgery. METHODS: The relationship between several variables (age, sex, hypertension, diabetes, and previous myocardial infarction, type of disease, preoperative ejection fraction, and congestive heart failure) and operative (30 days) mortality and late survival was analyzed. RESULTS: The overall 30-day mortality was 18.3 % (21 patients). It was 13 % (10/77 patients) for the isolated CABG group and 13.3 % (2/15) for the isolated AVR group. Patients undergoing combined valve and coronary surgery or multiple valve surgery had a higher perioperative mortality of 39.1 % (9/23) compared to the isolated CABG and isolated AVR patients. Perioperative death was also higher in patients with moderate and severe LV dysfunction, and in patients with diabetes. The duration of dialysis periods was not related to perioperative death. Mean follow-up was 26.4 +/- 29.7 months (0.1 to 104 months). Actuarial survival at 1 year and 5 years was 76 % and 55 % for isolated CABG, 59 % and 21 % for isolated AVR, and 44 % and 33 % for all other cases, respectively (log rank P = 0.001). CONCLUSION: Patients on dialysis have a high risk of perioperative mortality and poor long-term survival rates. Mortality is higher and survival is worse after combined CABG and valve-related procedures or multiple valve surgery than after isolated CABG and AVR.