Impact of concomitant cardiac procedure on coronary artery surgery in hemodialysis-dependent patients.

OBJECTIVE: Coronary artery bypass grafting (CABG) in hemodialysis-dependent patients is associated with high mortality and morbidity rates. This retrospective study was undertaken to identify the risk factors for in-hospital mortality for hemodialysis-dependent patients. METHODS: Subjects included 87 consecutive hemodialysis-dependent patients (81 men and 6 women), aged 47-82 years (mean age, 65 years), who underwent CABG. Operative procedures included CABG alone (n=77) and CABG with valve replacement, repair, or the Dor procedure (n=10). Thirty-one perioperative risk factors were subjected to univariate and multivariate analyses to identify the risk factors for hospital death. RESULTS: The overall in-hospital mortality rate, including operative death, was 14.9% (13/87). Univariate analysis showed the following 7 risk factors to be statistically significant predictors of hospital death: age > or = 70 years, a concomitant cardiac procedure, left ventricular ejection fraction <30%, left ventricular end-systolic volume index >70 ml/m2, a left main lesion, emergency/urgent surgery, and anemia (hemoglobin <10 mg/dl) (p<0.05 for each predictor). Multivariate logistic regression analysis confirmed that a concomitant cardiac procedure (chi-squared = 17.080, p=0.013) and age > or = 70 years (chi-squared = 9.112, p=0.019) are statistically significant independent risk factors for hospital death. CONCLUSION: A concomitant cardiac procedure and age > or = 70 years were identified as significant independent risk factors for hospital mortality after CABG for hemodialysis-dependent patients. These preoperative risk factors may help in predicting operative risks and improving clinical outcomes in hemodialysis-dependent patients undergoing CABG.

Coronary malperfusion due to type A aortic dissection: mechanism and surgical management.

BACKGROUND: Coronary malperfusion associated with aortic dissection is relatively rare, but when it occurs, it is fatal to the patient. To salvage such moribund patients, aggressive coronary revascularization concomitant with aortic repair is essential. We review the surgical results and mechanism of malperfusion in a group of 12 patients with coronary malperfusion caused by type A aortic dissection, and we discuss our surgical approach. METHODS: Between March 1990 and March 2003, 12 patients (6.1%) from a total of 196 consecutive patients with acute type A aortic dissection undergoing surgery suffered coronary malperfusion associated with the dissection. There were 4 men and 8 women (mean age, 60.8 +/- 8.3 years). Nine patients had acute myocardial infarction due to dissection before surgery, and 3 patients suffered coronary malperfusion after aortic declamping. RESULTS: Hospital mortality rate was 33.3% (4 patients). The mortality rate was higher than that in patients without coronary malperfusion (33.3% vs. 8.2%, p = 0.019). Three patients could not be weaned from cardiopulmonary bypass, and 1 patient died of heart failure in the intensive care unit. Involved coronary arteries included the right coronary artery (8 patients), left coronary (2 patients), and both (2 patients). Mechanisms of coronary obstruction were compression (2 patients), coronary dissection (7 patients), and coronary disruption (3 patients). Coronary artery bypass grafting was performed concomitant with aortic repair. CONCLUSIONS: Acute type A aortic dissection with coronary involvement is associated with high mortality rate, aggressive coronary revascularization and early aortic repair with simple techniques are necessary to salvage these critically ill patients.