On-pump coronary artery bypass surgery in high-risk patients aged over 65 years (EuroSCORE 6 or more): impact on early outcomes.

The results of on-pump coronary artery bypass graft (CABG) surgery in 166 high-risk elderly patients (EuroSCORE 6 or more; over age 65 years [mean 71.8 years]) were compared with 176 low-risk elderly patients (EuroSCORE below 6; over age 65 years [mean 68.8 years]). There was no significant difference in hospital mortality or number of grafts between the two groups. Rates of inotropic agent use, intra-aortic balloon pump insertion and atrial fibrillation, and the duration of intensive care unit and hospital stay were significantly higher in high-risk than low-risk patients. There were no significant differences in the incidence of major complications between the two groups. The results suggest that, in selected patients, on-pump CABG can be safely performed in high-risk patients over 65 years old with no effect on mortality.

The effects of N-acetylcysteine on pulmonary functions in patients undergoing on-pump coronary artery surgery: a double blind placebo controlled study.

OBJECTIVE: To investigate the effects of N-acetylcysteine (NAC) on pulmonary function tests and arterial blood gases in patients undergoing on-pump coronary artery surgery. PATIENTS AND METHODS: The effect of NAC was assessed within the scope of a prospective, single center, double-blind, placebo-controlled, parallel group study. Eighty-two patients undergoing coronary artery bypass grafting were randomized into two groups to receive either placebo (group 1, n = 40) or NAC (group 2, n=42). Both the NAC group and the placebo-receiving control group also included a COPD subgroup consisting of patients with an FEV1/FVC ratio of < 0.7 and an FEV1 value of 50-80%. Pulmonary function tests were performed preoperatively and on postoperative day 60. RESULTS: Both groups were similar with respect to age, gender, preoperative risk factors, ejection fraction (EF), mean cross-clamp time, ventilation time, intensive care unit (ICU) stay, atrial fibrillation (AF) and hospital stay (p > 0.05). Postoperative FVC and FEV1 values in group 1 and the postoperative FEV1, FEV1/FVC and FEF 25-75 values in group 2 were lower in comparison to their preoperative values. However, in both group 1 and 2, the decreases observed in these parameters were not statistically significant (p > 0.05). In the COPD subgroup of group 1, a postoperative decrease was observed in the FEV1 and FEF25-75 values, with the FEV1 decreasing by 4.55%, and the FEF25-75 decreasing by 4.2% (p < 0.05). In the COPD subgroup of group 2, no significant decrease was observed in the pulmonary function test values (p > 0.05). CONCLUSIONS: This study demonstrated that NAC administration in COPD patients undergoing on-pump coronary artery surgery resulted in the preservation of pulmonary functions.

Early postoperative candida colonization in alimentary canal in patients undergoing open heart surgery.

AIM: To examine the frequency and factors predisposing to candidiasis in the digestive tract in the early postoperative period after open heart surgery. METHODS: One hundred patients undergoing open heart surgery were enrolled in this study. Patients were divided into 2 groups in regard to Candida spp. colonization. Group A means increased Candida spp. colonization after open heart surgery (31/100). Group B indicates unchanged Candida spp. colonization after open heart surgery (69/100). Samples were obtained from both oral and anal mucosa in 3 different periods of operation: 1) preoperatively (stage 1), 2) at the end of the first hour in the intensive care unit (stage 2), 3) 24 hours after operation (stage 3). Findings were compared with both preoperative and intraoperative parameters. For fungal isolation Sabourauds dextrose agar and blood agar were used. RESULTS: In Group A (31), there was a significant relationship between the samples in stage 1 and 2 (p=0.031), and also a significance between stage 1 and 3 (p=0.048). Comparison between Candida positive and negative groups (Group A and B) did not reflect any statistical significance (p>0.05). CONCLUSIONS: Candida colonization in the alimentary canal in the early postoperative period after open heart surgery is due to individual preoperative features. However, early postoperative Candida colonization in the digestive tract is not a risk factor for sepsis unless the patient has an additional risk factor leading to prolongation of length of stay in the intensive care unit.

Aorto-pulmonary artery fistula: an unusual complication of ascending aortic aneurysm.

We report an unusual outcome of an ascending aorta aneurysm ruptured into the main pulmonary trunk. After successful emergency repair, an acute respiratory distress syndrome developed perioperatively and complicated the postoperative period. The patient could not be weaned from mechanical ventilation for a long time. The patient was discharged on the 62nd day of admission in good condition.

Minimally invasive mitral valve surgery: the subxiphoid approach.

BACKGROUND: This report describes mitral valve replacement using a unique subxiphoid approach with a lower ministernotomy and a skin crease incision and compares the operative and echocardiographic results to patients undergoing mitral valve replacements using previously described strategies. METHODS: Fifty-four patients underwent mitral valve replacement using a subxiphoid approach (group 1); 32 patients underwent mitral valve replacement, 11 patients underwent mitral valve replacement + tricuspid reconstruction, 2 patients underwent mitral valve replacement + tricuspid valve replacement, and 9 patients underwent mitral reconstruction. This group of patients was compared to 11 patients who underwent mitral valve replacement through a superior ministernotomy (group 2) and 29 patients who underwent mitral valve replacement with full median sternotomy (group 3, 22 mitral valve replacements, 2 mitral valve replacements + tricuspid reconstruction, 2 mitral reconstructions, and 3 mitral reconstructions + tricuspid reconstruction). RESULTS: There was no operative mortality in all groups. The operation lasted significantly longer in group 2 patients compared to group 1 and 3 patients (p < 0.01). Postoperative mediastinal drainage was significantly lower in groups 1 and 2 (p < 0.001). Pain assessment revealed no difference between the groups. Three patients in group 1 presented with pericardial effusion. Except for this complication, early postoperative echocardiographic findings of the patients were similar in all three groups. All patients were in New York Heart Association functional class I or II at the second postoperative month, irrespective of the surgical technique used. CONCLUSIONS: There was no prominent superiority of the ministernotomy approaches over the standard median sternotomy approach. However, the reliability of the subxiphoid approach is documented echocardiographically and any type of mitral replacement can be performed with this approach.

Routine coronary arteriography before abdominal aortic aneurysm repair.

BACKGROUND: As cardiac complications constitute the principal cause of early and late morbidity and mortality after the surgical treatment of abdominal aortic aneurysm (AAA), a prospective study was planned to evaluate the effects of revascularization of coronary arteries on survival after AAA repair during early and long-term follow-up periods. PATIENTS AND METHODS: A total of 125 patients underwent elective repair of AAA between 1986 and 1994. Coronary arteriography was performed in all cases. All cases with critical left anterior descending artery (LAD) lesions underwent a coronary artery bypass operation either simultaneously or shortly before AAA repair. In addition, percutaneous transluminal coronary angioplasty (PTCA) was performed for symptomatic and critical stenosis of arteries other than the LADs, or if noncritical but symptomatic stenosis of the LADs existed. Early and late follow-up data were obtained for all cases, and late-term cumulative survival rates were calculated. RESULTS: Coronary artery lesions were found in 66 (53%) cases. In 24 cases, AAA repairs were performed 2.3 (mean) months after coronary artery bypass grafting (CABG), whereas in 4 cases both procedures were performed simultaneously. PTCA was performed in 4 cases 3 to 4 days prior to the abdominal surgery. Even though the coronary artery lesions were found inoperable in 7 cases, these patients underwent repair of AAA because of rapidly expanding and painful aneurysms. Early mortality rate was 4% (5 cases), in which 3 of these were from the group inoperable for CABG. A mean follow-up of 3.17 years (3 to 87 months) was achieved for all discharged patients. Cumulative survival rates for 6 months and 1, 2, 3, and 6 years were 99%, 99%, 95%, 93%, and 89%, respectively. CONCLUSIONS: The results of this study emphasize the importance of coronary artery revascularization for early, and especially for late, survival after AAA repair.

Long term results of mitral valve replacement with preservation of the posterior leaflet.

BACKGROUND AND AIMS OF THE STUDY: It is commonly held that preservation of the annulo-ventricular continuity during mitral valve replacement has a beneficial effect on postoperative ventricular function. This paper presents our eight-year experience with this technique. MATERIALS AND METHODS: From 1986 to December 1992, 120 patients with rheumatic valve disease underwent mitral valve replacement (MVR) combined with preservation of the posterior leaflet of the mitral valve. The mean age was 33.87 years (range 16 to 63). The preoperative New York Heart Association (NYHA) class was III in 64% of the patients and IV in 3%. The early (30 day) mortality rate was 2.5% (3/120). Follow up was 100% complete. The total cumulative follow up was 477 patient-years (pty) with a mean 3.94 years (range: 2-8 years). RESULTS: The actuarial survival rate (including hospital mortality) was 87.6% at eight years. Advanced age (p = 0.0457), increased preoperative functional capacity (p = 0.0251), increased preoperative end-systolic diameter (p = 0.0352) and combined tricuspid reconstruction (p = 0.0001) were found to be independent parameters for a lower actuarial survival rate. Six patients (1.25%/pty) developed thromboembolic complications. Two of these were cerebrovascular accidents (0.41%/pty) and four were caused by mechanical valve thrombosis (1.83%/pty). Freedom from thromboembolic complications (including mechanical valve thrombosis) was 89.8% +/- 7.9%. Fifteen patients (3.14%/pty) developed valve failure, four (0.83%/pty) mechanical valve thrombosis and nine (1.88%/pty) bioprosthetic valve failure. Freedom from reoperation was 60.7% +/- 16.1%. One patient with a St. Jude Medical valve (0.2%/pty) suffered from prosthetic valve endocarditis. Three patients (0.62%/pty) died during the follow up period, and, freedom from all valve related complications was 51.4% +/- 16.1% at eight years. CONCLUSION: Preservation of the posterior leaflet during mitral valve replacement reduces the risk of early mortality and did not cause additional complications to the patients. Despite the beneficial effects of this technique in the long term this technique did not increase the long term survival in patients with associated impaired valvular and/or ventricular function.

Experimental evaluation of retrograde cerebral perfusion by single photon emission computed tomography technique (SPECT).

BACKGROUND: Protection of the brain is of vital importance during aortic arch aneurysms. In this study efficiency of retrograde cerebral perfusion was evaluated with the use of single photon emission computed tomography technique (SPECT) by using 99mTc hexamethylpropylene amine oxime (HMPAO). METHODS: Four animals were used. The internal maxillary vein was the site of retrograde cerebral perfusion. The animals were studied after the heart rate and respiration were stopped with the use of the high dose drug administration and the brain was perfused with cold Ringer's lactated solution. After this procedure, 99mTc HMPAO-SPECT study was performed. RESULTS: In one animal we did not get any cerebral image because of the competent venous valve in the internal maxillary vein. In the remaining animals, normal brain perfusion was achieved. CONCLUSIONS: 99mTc HMPAO-SPECT study documented that blood flow via the retrograde way meets the metabolic demand of the brain. Retrograde delivery of 99mTc HMPAO did not conclude any poorly perfused area in the brain when in given both sides and all parts of the brain can be effectively perfused by cerebral venous system in hypothermic conditions.

Giant left atrial thrombus formation in patient with a previous coronary artery bypass grafting.

Free-floating left atrial ball thrombus is a rare condition. We report a giant left atrial ball thrombus which was removed under surgery uneventfully, in a 48-year-old male patient with the presence of sinus rhythm and no valvular disease with previous off-pump coronary artery bypass surgery.

Hepatic vein stenosis developed during living donor hepatectomy and corrected with peritoneal patch technique: a case report.

An 18-year-old male living donor for his father with end-stage liver cirrhosis due to hepatitis B underwent an extended right lobe donor hepatectomy. The middle hepatic vein was visualised on the cut surface of the graft and dissected up to the confluence of the middle and left hepatic veins. After vascular clamping, right and middle hepatic veins were cut to removed the graft. While starting the stump closure, the clamp over the middle hepatic vein slipped and the vein stump sutured quickly under suboptimal exposure. Soon after this closure, the remnant liver showed increasing congestion. Intraoperative Doppler ultrasound revealed obstruction of venous outflow at the remnant left liver due to stenosis in the left hepatic vein. Under total hepatic vascular occlusion, the sutures were removed from the narrowed left hepatic vein. A 2 × 2 cm peritoneal patch from the subcostal area that was prepared to close the defect was sutured to the edges of the left hepatic vein defect. Venous congestion of the liver disappeared when the clamps were removed. Intraoperative Doppler ultrasound confirmed normal hepatic venous flow. The postoperative course of the donor was uneventful. There was no clinical, biochemical, or radiological problems at 47 months of follow-up. An autogenous peritoneal patch may be a good option to repair vascular defects, which are not suitable for primary sutures, due to easy accessibility and size adjustment, cost effectiveness, as well as relatively low risk of infection and thrombosis. Close dissection of the left hepatic vein during parenchymal transection over the middle hepatic vein can result in narrowing, particularly at the bifurcation of the middle/left hepatic veins that can cause congestion in the remnant liver. When we include the middle hepatic vein with the right graft, we now believe that dissection away from the left hepatic vein seems much more secure for donors.

Pre-operative trans-thoracic doppler ultrasonography evaluation and intraoperative manual evaluation of the left internal thoracic artery in patients with type 2 diabetes with coronary artery disease.

Patients with coronary artery disease, with (n = 25) and without (n = 59) type 2 diabetes, who were scheduled to undergo coronary artery bypass grafting were enrolled in this prospective study. The left internal thoracic artery (LITA) was assessed for graft suitability before surgery by trans-thoracic Doppler ultra sonography and during surgery by manual measurement. Significant differences were seen between preoperative and intra-operative LITA blood flow rates and LITA diameters, and the values of each at the two time points showed significant correlation, suggesting that pre-operative measurements largely related to intra-operative conditions. The pre-operative and intra-operative LITA blood flow rates and LITA diameters were not significantly different between patients with and without type 2 diabetes. Pre-operative LITA blood flow was monophasic in three patients without diabetes and the LITA grafts of these patients were deemed unsuitable for implantation during surgery. It is concluded that type 2 diabetes does not seem to have a negative effect on the suitability of LITA grafts. In addition, trans-thoracic Doppler ultrasonography is an easy, cost-effective, reproducible and non-invasive examination method, which may help in the evaluation of LIMA function and contribute to graft selection.

Complete myocardial revascularization using arterial grafts only in patients with unstable angina: impact on early outcome.

OBJECTIVE: The aims of this study were 1) to assess early clinical outcomes for patients with unstable angina (UA) who undergo urgent/emergent coronary artery bypass grafting (CABG); and 2) to evaluate the feasibility and safety of complete revascularization using strictly arterial grafts in this patient group. PATIENTS AND METHODS: Between September 2001 and May 2005, a total of 961 patients underwent CABG at our center. One hundred and sixty-seven (17.4 %) of these individuals underwent urgent or emergent CABG because of UA, and 794 (82.6 %) underwent elective CABG for stable angina (SA). Of the 167 patients with UA, 59 (35.3 %) underwent complete revascularization using arterial grafts only (AO subgroup: internal thoracic arteries and radial arteries) and the other 108 received a combination of arterial and venous grafts (AV subgroup: 1 internal thoracic artery plus saphenous vein grafts). RESULTS: The UA group had a significantly higher proportion of women and a significantly higher rate of left main coronary artery disease than the SA group ( P = 0.016 and P = 0.0001, respectively). Cardiopulmonary bypass time was significantly longer in the UA group ( P = 0.01). Higher proportions of the UA group required inotropic support ( P = 0.001), intra-aortic balloon pump support ( P = 0.001), and re-exploration for bleeding or cardiac tamponade ( P = 0.005). This group also had a significantly longer mean time on mechanical ventilation ( P = 0.001) and a longer mean intensive care unit stay ( P = 0.01). The rates of operative mortality (first 30 days) in the SA and UA groups were 1.8 % and 6 %, respectively ( P = 0.001). There were no statistical differences between the AO and AV subgroups with respect to any of the preoperative or intraoperative findings. The AO group had a significantly shorter mean intensive care unit stay than the AV group ( P = 0.05). The AV group had a roughly fivefold higher operative mortality than the AO group (8.3 % vs. 1.7 %, respectively), but this difference was not statistically significant ( P = 0.17). CONCLUSION: Urgent or emergent CABG in the setting of UA is associated with increased but acceptable rates of mortality and morbidity. Complete myocardial revascularization using arterial grafts only (combinations of internal thoracic and radial arteries) is feasible and safe in this patient group.

Atrial fibrillation after coronary artery bypass grafting in elderly patients: incidence and risk factor analysis.

OBJECTIVE: New-onset atrial fibrillation (AF) is the most frequent arrhythmic complication after coronary artery bypass grafting (CABG). Elderly patients who undergo this operation may have a different risk profile from the general population. The aim of this study was to identify risk factors for post-CABG AF in the elderly population. METHODS: Between September 2001 and December 2005, 426 elderly patients (age >/= 65 years) underwent CABG at our center. Ninety-one developed post-CABG AF (AF group), and the other 335 (no-AF group) did not develop this complication. Multivariate analysis (odds ratio, +/- 95 % CI, P value) was used to identify independent clinical predictors of post-CABG AF. RESULTS: The incidence of post-CABG AF in elderly patients during the study period was 21.4 %. Multivariate analysis identified age (OR 1.07, P < 0.009), age >/= 75 years (OR 1.77, P < 0.042), preoperative renal insufficiency (OR 5.09, P < 0.035), EuroSCORE (OR 1.18, P < 0.038), and cross-clamping time (OR 1.02, P < 0.012) as predictors of AF occurrence. The AF group had a significantly longer mean intensive care unit (ICU) stay (3.8 +/- 4.7 vs. 2.5 +/- 1.3 days for AF vs. no-AF; P = 0.0001), and a significantly higher proportion of patients with prolonged (>/= 6 days) ICU stays (8.8 % vs. 3.2 %, respectively; P = 0.033). Hospital mortality was 3.2 % in the no-AF group and 2.2 % in the AF group ( P = 0.74). CONCLUSION: This study of elderly patients reveals some novel predictors of post-CABG AF, most notably preoperative renal insufficiency and EuroSCORE. It is important to identify risk factors for post-CABG AF in all patient groups as this knowledge might lead to better prevention of this problem and its potential consequences.

Minimally invasive replacement of ascending aortic aneurysms: intermediate term results.

BACKGROUND: Minimally invasive techniques have gained recent interest in the realm of cardiac surgery. This report describes our initial experience with graft replacement of ascending aortic aneurysms using a superior mini-sternotomy approach. METHODS: Between March 1997 and October 1997, four patients underwent operation for ascending aortic aneurysm via superior mini-sternotomy approach. There were two female and two male patients, ranging in age from 52 to 62 years (mean 53.7 +/- 7.6). All patients had the stigmata of Marfan's syndrome. Mean diameter of the ascending aortas was 6.1 +/- 0.9 cm. Composite graft replacement with coronary reimplantation was performed in all cases. In one patient hemiarch replacement was performed under total circulatory arrest. There was no hospital (30-day) mortality. Mean aortic cross clamp and cardiopulmonary bypass times were 63 +/- 14.1 minutes (range 44 to 78) and 116.7 +/- 43.3 minutes (range 81 to 177), respectively. One patient was re-explored for bleeding. RESULTS: Lengths of hospital stay ranged from 5 to 7 days (mean 5.5 +/- 1). Patients were followed-up for at least 18 months. One patient suffered a fatal stroke in her third postoperative month. All surviving patients were in NYHA Class I at the sixth postoperative month and thereafter. CONCLUSIONS: Minimally invasive graft replacement of ascending aortic aneurysms can be performed safely and effectively. Long term results are likely to be similar to those of conventional cases performed through a full median sternotomy.

Does cardiopulmonary bypass alter plasma level of tumor markers? CA 125 and carcinoembryonic antigen.

BACKGROUND: In addition to malignant diseases, acute and chronic inflammations may elevate plasma levels of tumor markers CA 125 and carcinoembryonic antigen (CEA). Cardiopulmonary bypass (CPB) causes a generalized inflammatory response. In this study, we have investigated the effect of CPB on plasma levels of CA 125 and CEA. METHODS: We measured plasma levels of CA 125 and CEA in patients undergoing coronary artery bypass grafting (CABG) with CPB (Group 1, n = 21), and in patients who underwent off-pump CABG, that is, without CPB (Group 2, n = 16). Blood samples were collected preoperatively, and on postoperative days 1, 6, and 12. RESULTS: Within both groups, CEA plasma levels were not significantly influenced in any samples. Comparing with preoperative values, CA 125 values elevated significantly on postoperative days 6 and 12 within both groups. It was observed that the elevation of CA 125 plasma levels in these samples were significantly higher in Group 1. CONCLUSIONS: The results indicate that CPB elevated plasma level of CA 125. However, clinical importance of this finding needed further evaluation.