Surgical techniques for emergent repair of post-infarction ventricular septal defect: compare endocardial patch and infarct exclusion method with traditional method.

BACKGROUND: The traditional surgical repair of post-infarction ventricular septal defect (VSD) includes excision of necrotic myocardium and approximation of the remaining of healthy ventricular wall and septal portion. The exclusion method emphasizes no excision of infarcted myocardium, preservation of the left ventricular geometry and exclusion of infarction area. We discuss our experiences in 13 patients and compared the results obtained from 2 different surgical methods. METHODS: From July 1996 to December 2001, 13 patients with post-infarction VSD received emergent repair. Seven patients were repaired in the traditional way and the other 6 with infarct exclusion method. There were 9 men and 4 women, ranging in age from 57 to 79. In the traditional group, all 7 patients were classified as NYHA IV and supported by intra-aortic balloon counter-pulsation (IABP) and 4 patients were for synchronous coronary bypass grafting. Patients using exclusion method were the 1 classified as NYHA III and 5 as IV with cardiogenic shock and supported by IABP. Coronary bypass grafting was performed concomitantly in 2 patients. RESULTS: Five patients died within 30 days after the surgery. Four patients (mortality rate = 57.1%) had reconstruction in traditional way and 1 (mortality rate = 16.6%) in exclusion way. The complication rate was higher in the traditional group (= 100%, n = 7, p = 0.005). In the traditional group, 1 patient received heart transplantation due to persistent severe pump failure and recovered well. Two received tracheostomy due to respiratory failure and 1 died 2 months later. In the group of exclusion method, 1 patient suffered recurrent VSD 2 days after the first surgery and died due to ventricular arrhythmia. CONCLUSIONS: The surgical mortality caused by acute post-infarction VSD has decreased with endocardial patch and infarction exclusion method. Rapid diagnosis, appropriate preoperative management and delicate surgical repair improve the overall results and help to attain long-term survival.

Is off-pump coronary artery bypass grafting in multivessel feasible.

BACKGROUND: "Off-pump" coronary artery bypass grafting (OPCABG) became more popular in recent years for its potential advantages of reducing perioperative morbidity related to cardiopulmonary bypass (CPB). We retrospectively analyzed the early results of multivessel OPCABG to compare them with conventional CABG under CPB. METHODS: From April 2000 to Oct 2000, 15 patients received multivessel OPCABG (group A). CTS or Octopus II stabilizer was used with coronary anastomosis. "Auto-perfusion system" was used at late stage of our series for myocardial protection in the procedure. At the same time, patients who received primary isolated CABG under CPB were compared as control (group B). RESULTS: There was no operative mortality or major morbidity in the group of multivessel OPCABG. Two patients who failed multivessel OPCABG due to hemodynamics compromise were converted to conventional CABG under CPB uneventfully. The amount of operative blood loss and donor blood transfusion, the duration of postoperative mechanical ventilation support, the mean intensive care unit stay and postoperative hospital stay were less in group A. CONCLUSIONS: Multivessel OPCABG is feasible in surgical techniques in selected patient. It is associated with minimal operative mortality and morbidity partly because of obviating the adverse effect of CPB. Prospective study with long-term follow-up is needed to better define the role of OPCABG.

Is combined abdominal aortic aneurysm repair and coronary artery bypass grafting feasible?

BACKGROUND: Significant coronary artery disease requiring coronary artery bypass grafting (CABG) may co-exist with large abdominal aortic aneurysm (AAA) in some patients. We reviewed our experience in either staged or simultaneous operation. METHODS: The records of all patients receiving both CABG and AAA repairs in recent 7 years were retrospectively reviewed. The patient demographics, severity of coronary disease, AAA size, duration of staged procedures, perioperative morbidity and mortality rates as well as the hospital cost were analyzed. RESULTS: From June 1993 to Sept 2000, totally 14 patients received both CABG and AAA repair, including 6 patients for simultaneous operation (group A, 42.8%) and 8 for staged operation (group B, 57.2%) with CABG first. Patients in the group A were younger and with larger AAA. There was neither operative mortality in both group nor interprocedure AAA rupture in group B. Total postoperative hospital stay and hospital cost were significantly decreased in group A than in group B rehospitalized patients. CONCLUSIONS: Simultaneous CABG and AAA repair is feasible in surgical technique. In those younger patients with larger AAA, combined surgery could be performed as safely as staged procedures.