Clinical evaluation of leukocyte filtration as an alternative anti-inflammatory strategy to aprotinin in high-risk patients undergoing coronary revascularization.

PURPOSE: The use of aprotinin in cardiac surgery is associated with overriding safety concerns. Therefore, there is increased research on alternatives. This study investigated the relative benefits of strategic leukofiltration on polymer-coated extracorporeal circuits (ECC), aprotinin, and combined therapy in high-risk patients. METHODS: Eight hundred and seventy-five patients (EuroSCORE 6+) undergoing coronary revascularization over a 4-year period were prospectively randomized to one of four perfusion protocols: Group 1: polymethoxyethylacrylate (PMEA)-coated circuits + leukocyte filters (n = 214); Group 2: uncoated ECC + full Hammersmith aprotinin (n = 212); Group 3: PMEA-coated ECC + leukofilters + full Hammersmith aprotinin (n = 199); and Group 4: control-no treatment (n = 250). Blood samples were collected at times T1: following the induction of anesthesia; T2: following heparin administration; T3: 15 min after cardiopulmonary bypass (CPB); T4: before cessation of CPB; T5: 15 min after protamine reversal; and T6: in the intensive care unit. RESULTS: The serum interleukin-2 levels were significantly lower at T3, T4, and T5 in all study groups. C3a levels were significantly lower at T3. Creatine kinase MB and lactate levels demonstrated well-preserved myocardia in both leukofiltration groups (P < 0.05). Neutrophil CD11b/CD18 levels were significantly lower for all study groups. Postoperative bleeding and respiratory support time were lower in all study groups. CONCLUSION: Leukofiltration on coated circuits significantly reduced bleeding and inflammatory response related to CPB with no adverse effects, and may be a possible alternative to pharmacological intervention.

Clinical performance and biocompatibility of hyaluronan-based heparin-bonded extracorporeal circuits in different risk cohorts.

This prospective randomized study compares novel hyaluronan-based heparin-bonded circuits vs. uncoated controls across EuroSCORE patient risk strata including biomaterial evaluation. Over a two-year period, 90 patients undergoing coronary artery bypass grafting were prospectively randomized to one of the two perfusion protocols: Group 1 was treated with hyaluronan-based heparin-bonded preconnected circuits (Vision HFO-GBS, Gish, CA, USA) and Group 2 with identical uncoated controls. Each group was composed of three subgroups (n=15) with respect to preoperative evaluation of low (EuroSCORE 0-2), medium (3-5) and high (6+) risk patients. Blood samples were collected after induction (T1) and heparinization (T2), 15 min after cardiopulmonary bypass start (T3), before cessation of CPB (T4), 15 min after reversal (T5), and the first postoperative day (T6). In high-risk patients, platelet counts demonstrated significant preservation at T4, T5 and leukocyte counts were lower at T5 in hyaluronan group (P

Clinical efficacy of two-phase leukocyte filtration in high-risk patients undergoing coronary revascularization with cardiopulmonary bypass.

The purpose of this study was to investigate the clinical outcome, inflammatory response and myocardial function in high-risk patients undergoing three different leukocyte depletion strategies. Over a four-month period, forty patients (EuroSCORE 6+) undergoing coronary revascularization were prospectively randomized to one of the four perfusion protocols: Group 1 (N=10): Conventional circuits (ECC) + two leukocyte filters (LG6B, Pall, USA) with the method of two-phase (continuous + strategic) leukofiltration; Group 2 (N=10): ECC + single leukocyte filter with the method of continuous leukofiltration; Group 3 (N=10): ECC + single leukocyte filter with the method of strategic leukofiltration; Group 4 (N=10) CONTROL: ECC without leukocyte filtration. Blood samples were collected at T1: Baseline, T2: On CPB, T3: X-Clamp, T4: Off CPB, T5: ICU24 and T6: ICU48. Perioperative follow-up was thoroughly monitored. Leukocyte counts in double filter and strategic filtration groups demonstrated significant differences at T4 (p < .05 vs. control). TNFalpha levels were significantly lower in Group 1 at T4 and procalcitonin levels at T5 and T6 (p < .05 vs. control). CKMB levels demonstrated well preserved myocardium in double filter group (p < .05 vs. control). Brain natriuretic peptide levels in double filter group were significantly lower at T5 and T6 with respect to Group 2 (p <.05) and control (p <.001). Matrixmetallopeptidase 9 and D-Dimer levels in double filter group were significantly lower at T5 and T6 (p <.05 vs. control).Two-phase leukofiltration is associated with some compound benefit over continuous deployment in high-risk patients. A larger more powerful study than this pilot one is warranted for further evaluation.

Clinical evaluation of minimized extracorporeal circulation in high-risk coronary revascularization: impact on air handling, inflammation, hemodilution and myocardial function.

OBJECTIVE: We examined intraoperative microembolic signals (GME), inflammatory response, hemolysis, perioperative regional cerebral oxygen saturation (rSO(2)), myocardial protection and desorbed protein amount on oxygenator fibers in high-risk patients undergoing coronary revascularization (CABG) with minimized and conventional cardiopulmonary bypass (CPB). METHODS: Over a ten-month period, 40 Euroscore 6+ patients undergoing CABG were prospectively randomized to one of the two perfusion protocols (N=20): Group 1: minimized extracorporeal circuits (Mini-CPB) (ROCsafe MPC, Terumo, Ann Arbor, MI, USA) and Group 2: conventional extracorporeal circuits (CECC) (Capiox SX18, Terumo, USA). Serum creatinine kinase-MB (CKMB), free hemoglobin, interleukin-6 (IL-6) and C3a levels were measured. Blood samples were collected at T1: following induction of anesthesia; T2: thromboelastography control; T3:15 min after commencement of CPB; T4: before cessation of CPB; T5: 15 min after protamine reversal and T6: ICU. RESULTS: Serum IL-6 levels were significantly lower in the Mini-CPB group at T4 and T5 and C3a levels were significantly less in the Mini-CPB group at T3, T4 and T5 vs. CECC (p<0.01). CKMB levels in coronary sinus blood demonstrated well preserved myocardium in the Mini-CPB group. Percentage expression of neutrophil CD11b/CD18 levels were significantly lower in the Mini-CPB group at T4 and T5 (p<0.05). There were no significant differences in air handling characteristics or free plasma hemoglobin levels in either circuit. rSO(2) measurements were significantly better at T3 and T4 in the Mini-CPB vs. CECC (p<0.05) and always higher in the Mini-CPB during follow-up. Blood protein adsorption analysis of oxygenator membranes demonstrated a significantly increased amount of microalbumin on CECC fibers (p<0.05). CONCLUSION: Mini-CPB provided a comfort and safety level similar to conventional control via satisfactory air handling, attenuated inflammatory response and hemodilution, with a better clinical outcome in patients undergoing high-risk CABG.

Clinical and biomaterial evaluation of hyaluronan-based heparin-bonded extracorporeal circuits with reduced versus full systemic anticoagulation in reoperation for coronary revascularization.

OBJECTIVE: This prospective randomized study compares full and reduced heparinization on novel hyaluronan-based heparin-bonded circuits vs. uncoated controls under challenging clinical setting including biomaterial evaluation. METHODS: 100 patients undergoing reoperation for coronary artery bypass grafting were allocated into two equal groups (n = 50): Group one was treated with hyaluronan-based heparin bonded preconnected circuits (Vision HFOGBS, Gish, California, USA) and Group two with identical uncoated controls (Vision HFO, Gish, USA). In the study group, half of the patients (n = 25) received low-systemic heparin (125 IU/kg, ACT >250 s) or full dose like control group. Blood samples were collected after induction of anesthesia (T1) and heparin administration before cardiopulmonary bypass (CPB) (T2), 15 min after initiation of CPB (T3), before cessation of CPB (T4), 15 min after reversal with protamine (T5), and the first postoperative day at 08: 00 h (T6). RESULTS: Platelet counts were preserved significantly better at T5, T6 in hyaluronan groups (P < 0.05 vs. control). Serum IL-2 levels were significantly lower at T4, T5 in both hyaluronan groups and C3a levels at T4 and T5 only in low-dose group (P < 0.05). Troponin-T levels in coronary sinus blood demonstrated well preserved myocardium in hyaluronan groups. No significant differences in thrombin-antithrombin levels were observed between full and low-dose heparin groups at any time point. Amount of desorbed protein was 1.41 +/- 0.01 in full and 1.43 +/- 0.01 in low dose vs. 1.78 +/- 0.01 mg/dl in control (P < 0.05). CONCLUSION: Hyaluronan-based heparin-bonded circuits provided better clinical outcome and less inflammatory response compared with uncoated surfaces. Reduced systemic heparinization combined with hyaluronan-based heparin-bonded circuits is feasible and clinically well tolerated.

Right coronary system grafts: alone or together with left system grafts--angiographic results.

PURPOSE: The aim of this study is to compare the long-term graft patency between patients who had sequential or individual right posterior descending artery (RPDA) anastomosis. MATERIALS AND METHODS: Two hundred and forty-two patients underwent coronary artery bypass grafting (CABG) between June 1994 and December 2003. They were examined retrospectively with respect to coronary angiograghic data. [Group 1] Individually right system grafts in RPDA position (n=139). [Group 2] RPDA anastomosis sequentially with left system (n=103). Patency rates for posterior descending arteries in each group were separately calculated for each vessel quality category. RESULTS: The mean interval from operation to angiography was 50.6+/-48.9 months in group 1 vs 57.5+/-39.2 months in group 2 respectively. The overall patency rate was 66.2% (92/139) in group 1 and 78.6% (81/103) in group 2 (p=0.04). When the RPDA has good run-off capacity, the patency rate was 69.1% in group 1 and 85.2% in group 2. CONCLUSION: When the RPDA has good run-off capacity, snake grafts show excellent results and right and left coronary systems could be anastomosed sequentially.

Clinical effects of leukofiltration and surface modification on post-cardiopulmonary bypass atrial fibrillation in different risk cohorts.

OBJECTIVE: A manifestation of inflammatory injury to the heart, atrial fibrillation (AF), ranks among the most frequent and potentially life-threatening post-operative complications. METHODS: In a prospective randomized study, 120 patients undergoing CABG were allocated into two groups (N = 60): Group 1: Polymethoxyethylacry late-coated circuits + Leukocyte filters (Terumo,USA); Group 2: CONTROL: Uncoated circuits (Terumo,USA). Each group was further divided into three subgroups (N = 20) with respect to low (Euroscore 0-2), medium (3-5) and high (6+) risk patients. RESULTS: Serum IL-2 levels were significantly lower in the study group at T4 and T5 (p < 0.01). C3a levels showed significant differences in the leukofiltrated group at T4 and T5 (p < 0.05). CPKMB levels demonstrated well-preserved myocardium in the leukofiltration group, post-operatively. AF incidence was 10% (2 patients) in the study and 35% (7 patients) in the control cohorts (p < 0.05). Phagocytic capacity on fibers in filtered patients was significantly lower. CONCLUSION: Leukofiltration and coating significantly reduce the incidence, ventricular rate, and duration of AF after CABG via modulation of systemic inflammatory response and platelet preservation in high risk groups.

Experience with the Edwards MIRA mechanical bileaflet valve in the aortic and mitral positions.

The Edwards MIRA bileaflet mechanical prosthesis, a heart valve not yet available in the United States, is designed with a unique hinge mechanism, curved leaflets, and thin titanium housing. We performed this study to investigate its clinical performance and postoperative hemodynamic results. We implanted 58 Edwards MIRA prostheses in 51 patients in the aortic (n = 18), mitral (n = 26), and aortic and mitral (n = 7) positions. Patients' ages ranged from 25 to 84 years (mean age, 53.7 +/- 13.6). Operative mortality was 2% (n = 1), and late mortality was 4% (n = 2). Thromboembolic events were observed in 2 patients (valve thrombosis in 1 and a cerebrovascular event in 1). There were no complications related to anticoagulation. No signs of valvular dysfunction or paravalvular leakage were observed. Peak transvalvular gradients of the aortic prostheses ranged from 24.25 +/- 5.32 mmHg for the 21-mm valve to 11 +/- 1.41 mmHg for the 25-mm valve. The effective orifice area ranged from 1.99 +/- 0.12 cm2 for the 21-mm valve to 2.44 +/- 0.17 cm2 for the 25-mm valve. The mean transvalvular gradients of the mitral prostheses ranged from 5.85 +/- 2.91 mmHg for the 27-mm valve to 4.5 +/- 0 mmHg for the 31-mm valve. The effective orifice area ranged from 2.31 +/- 0.03 cm2 for the 27-mm valve to 2.64 +/- 0.05 cm2 for the 33-mm valve. These preliminary data suggest good hemodynamic function and a low rate of valve-related complications in the use of the Edwards MIRA mechanical prosthesis.

Comparison of polymethoxyethylacrylate-coated circuits with leukocyte filtration and reduced heparinization protocol on heparin-bonded circuits in different risk cohorts.

OBJECTIVES: The relative benefits of strategic leukofiltration on polymer-coated and low-dose heparin protocol on heparin-coated circuits were studied across EuroSCORE patient risk strata for three different cohorts. METHODS: In a prospective, randomized study, 270 patients undergoing coronary artery bypass grafting were allocated into three groups (n = 90): Group 1 - polymethoxyethylacrylate-coated circuits + leukocyte filters; Group 2 - polypeptide-based heparin-bonded circuits with reduced heparinization; and Group 3--CONTROL: uncoated circuits. Each group was further divided into three subgroups (n = 30), with respect to low- (EuroSCORE 0-2), medium- (3-5), and high- (6+) risk patients. Blood samples were collected at T1: following induction of anesthesia; T2: following heparin administration; T3: 15 min after CPB; T4: before cessation of CPB; T5: 15 min after protamine reversal; and T6: ICU. RESULTS: In high-risk cohorts, leukocyte counts demonstrated significant differences at T4 and T5 in Group 1, and at T4 in Group 2. Platelet counts were preserved significantly better at T4 and T5 in both groups (p < 0.05 versus control). Serum IL-2 and C3a levels were significantly lower at T3, T4 and T5 in Group 1, and T4 and T5 in Group 2 (p < 0.05). Postoperative bleeding, respiratory support time and incidence of atrial fibrillation were lower in the study groups versus control. Cell counts on filter mesh and heparin-coated fibers/ circuits were significantly higher in the high-risk cohorts versus uncoated fibers. Phagocytic capacity increased on filter mesh, especially in high-risk specimens. SEM evaluation demonstrated better preserved coated circuits. CONCLUSION: Leukofiltration and coating reduced platelet adhesion, protein adsorption, atrial fibrillation and reduced heparinization acted via modulation of systemic inflammatory response in high-risk groups.

A peeled off and entrapped intraaortic balloon catheter in the femoral artery: an unusual complication.

The intraaortic balloon is the most commonly used support device during perioperative period of cardiac surgery. A rare complication after its use is entrapment. In this case-report we present a 70-year-old man who had undergone coronary bypass and needed intraaortic balloon support early in the postoperative period with an extraordinary complication.

Effectiveness of intraaortic balloon pumping in patients who were not able to be weaned from cardiopulmonary bypass after coronary artery bypass surgery and mortality predictors in the perioperative and early postoperative period.

OBJECTIVE: The intraaortic balloon pump (IABP) is usually the first choice of mechanical device used for perioperative cardiac failure. The aim of this retrospective study was to determine the effectiveness of intraoperative IABP use in patients who could not be weaned from cardiopulmonary bypass (CPB) and to determine the possible perioperative and early postoperative prognostic factors for mortality. METHODS: Between June 1992-December 2001 a total of 69 patients who underwent coronary artery bypass grafting and required IABP support in weaning from CPB due to cardiac pump failure were included into the study. The mean age was 61.9+/-7.5 years. The effectiveness of IABP and preoperative, operative and postoperative risk factors for mortality were evaluated retrospectively. RESULTS: Following the insertion of IABP, 59 (85.5%) patients could be weaned from CPB whereas 10 patients (14.5%) could not. In the early postoperative period, 13 (22%) patients died due to cardiac pump failure. The average in-hospital mortality rate for patients who were treated with an IABP was found as 33.3% (23 patients). Univariate analysis identified left ventricular enddiastolic pressure, ventricular performance score, urgent operation and perioperative myocardial infarction as the risk factors for early death. The minor and major IABP related complications occurred in only 8 patients. CONCLUSION: Due to the contributory effects, effectiveness and low complication rate, IABP may be used in patients who cannot be weaned from CPB.

Comparison of circadian rhythm characteristics of blood pressure and heart rate in patients before and after elective coronary artery bypass surgery.

Coronary artery bypass grafting surgery (CABGS) is done to reperfuse the ischemic myocardium of coronary disease patients. This study was designed to analyze the circadian rhythm characteristics of blood pressure (BP) and heart rate (HR) of patients before and after CABGS. Fifty-one patients undergoing elective CABGS were studied; 21 patients received one, 12 two and 18 three or more grafts. BP was monitored for 24h before and after CABGS while patients were recumbent in the hospital. Systolic (S) and diastolic (D) BP and HR were assessed every 30 min. Of the 51 patients, 37 (73%) had nondipper 24h BP patterns (nocturnal decline in BP < 10% of daytime mean level) in the preoperative baseline assessment. The peak and MESOR (rhythm-adjusted 24h mean) values of the circadian rhythm in SBP, DBP, and pulse pressure (PP) significantly declined following surgery, while HR and rate-pressure product (RPP = SBP x HR) markedly increased. The double amplitude (peak-to-trough variation) of the circadian rhythm in SBP and DBP was significantly reduced postoperatively, and that of the rhythm in HR and RPP significantly increased. The slopes of the morning rise and evening dip in the 24h SBP profile were reduced significantly after bypass grafting. The corresponding slopes of the HR profile, in contrast, were markedly increased.

Angiographic assessment of sequential and individual coronary artery bypass grafting.

OBJECTIVE: In trying to answer the question about the controversial use of sequential grafts, we determined the mid-term angiographic outcome of patients in whom coronary artery bypass was performed with different types of vein grafts. METHODS: A total of 1034 coronary anastomoses on 724 saphenous vein grafts (SVGs) (apart from 497 left internal mammarian artery (LIMA) anastomoses) were assessed in 509 patients in an average of 55.4 +/- 17.6 months after coronary artery bypass grafting. RESULTS: The patency rates of sequential conduits were markedly higher than those of individual ones (86.6% vs 69.6%, p = 0.0001). Also, the anastomoses on the sequential conduits had better patency rates (80.6% vs 69.6%, p = 0.0001). This difference was even more pronounced in coronary arteries of poor quality/small (< 1.5 mm) diameter (68.9% vs 51.6%) for the sequential and individual grafts, respectively (p = 0.03). Also, the patency of the entire sequential conduit was lower when most distally located anastomosis was of poor runoff (45.2%). CONCLUSIONS: The patency of a sequential vein conduit is generally superior than that of an individual one, especially for poor runoff coronary vessels, provided that the most distally located anastomosis is performed on a good coronary artery in terms of quality and diameter. Using a minimal length of SVG is another advantage. However, failure of a single sequential conduit jeopardizes all of the anastomoses along that graft segment. Besides, being technically more demanding, technical expertise in performing a sequential anastomosis is probably among the important predictors of patency.

Clinical performance and biocompatibility of poly(2-methoxyethylacrylate)-coated extracorporeal circuits.

BACKGROUND: Poly(2-methoxyethylacrylate) is an amphiphilic organic polymer consisting of a hydrophobic backbone with pendant hydrophilic groups that has been reported to reduce protein and platelet adsorption in in vitro and ex vivo studies. METHODS: Sixty patients undergoing three-vessel coronary artery bypass grafting were divided into two equal groups. Group 1 had operation with Capiox poly(2-methoxyethylacrylate) coated SX18R oxygenators with noncoated circuits, and group 2 had operation with all noncoated circuits. Hemodynamic variables, blood and urine test results, hematologic variables, complement fractions, C3a and C4d, and interleukin-6 levels were documented preoperatively (T1), on cardiopulmonary bypass (T2), before cessation of cardiopulmonary bypass (T3), after protamine sulfate reversal (T4), and on the first postoperative day (T5). Protein electrophoresis was performed at T1 and T5. Blood cell adhesion and aggregation on fibers were analyzed with optical microscopy, and desorbed protein was evaluated quantitatively by a spectrophotometer using samples obtained when the oxygenators were dismantled after cardiopulmonary bypass. RESULTS: Platelet counts in group 1 demonstrated significant differences at T3, T4, and T5 (p < 0.05) versus group 2 and white blood cell counts in group 1 versus group 2, at counts T4 and T5. Albumin levels were significantly better preserved in group 1 at T4, and T5 and fibrinogen levels, at T3 and T5 (p < 0.05). On electrophoresis, the postoperative albumin level was 57.9% +/- 3% in group 1 versus 50.2% +/- 3% in group 2 (p < 0.05). Postoperative hemorrhage was 452 +/- 35 mL in group 1 and 612 +/- 35 mL in group 2 (p < 0.05). Duration of intubation was significantly lower (p < 0.05) in group 1, as was need of blood transfusion (p < 0.01). More platelet adhesion and aggregation were demonstrated on noncoated oxygenator fibers. The amount of desorbed protein was 0.13 +/- 0.01 mg/dL versus 0.012 +/- 0.001 mg/dL (p < 0.001) on noncoated versus coated fibers, respectively. CONCLUSIONS: Poly(2-methoxyethylacrylate)-coated oxygenators reduce platelet adhesion, platelet aggregation and protein adsorption. This surface provides a better perioperative clinical status through platelet-, albumin-, and fibrinogen-sparing effects.

Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias and pericardial effusion after coronary artery bypass grafting.

OBJECTIVE: The aim of this prospective study was to demonstrate the effectiveness of posterior pericardiotomy in reducing the incidence pericardial effusions and consequently reducing the related supraventricular tachyarrhythmias and development of delayed posterior cardiac effusions. METHODS: This prospective randomized study was carried out in 150 patients undergoing coronary artery bypass grafting in Bayindir Hospital Department of Cardiovascular Surgery between April 2000 and October 2001. One hundred and fifty patients were divided into two groups; each group included 75 patients. A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in posterior pericardiotomy group (group I). Posterior pericardiotomy was not performed in conventional treatment group (group II). RESULTS: Atrial fibrillation was developed in seven patients (9.3%) in group I and in 24 patients (32%) in group II (P<0.001). Atrial flutter and other supraventricular tachyarrhythmia (SVT) prevalence was not statistically significant. Early pericardial effusion was developed 42.6% (32/75) and 10.6% (8/75), respectively, in group II and group I (P<0.0001), but no late pericardial effusion developed in group I despite seven (9.3%) late pericardial effusions developing in group II (P<0.013). CONCLUSION: Posterior pericardiotomy is a simple, safe and effective technique for reducing not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.

Does microalbuminuria in diabetic patients affect the postoperative course after coronary artery bypass surgery?

OBJECTIVES: Microalbuminuria is a predictor of microvascular disease and a marker for multiorgan damage in diabetic patients. It has been proposed that in diabetic patients who would undergo coronary artery bypass surgery (CABG), microalbuminuria is associated with poor postoperative outcome, higher incidence of early and late morbidity and mortality. METHODS: Microalbuminuria was prospectively studied preoperatively in 24-h urinary collections for 257 consecutive diabetic patients in a 2-year period. One hundred and sixty-eight patients (65.4%) were defined as microalbuminuria negative (Group A), and 89 (34.6%) were microalbuminuria positive (Group B) with respect to the cut-off point 30 mg/24 h. RESULTS: The two groups did not differ with respect to preoperative and operative data, except that preoperative blood glucose levels (P=0.046), blood urea nitrogen (P=0.001), and creatinine (P=0.001) were higher and creatinine clearance was lower (P=0.025) in Group B. Postoperative serum creatinine levels on different days were higher in microalbuminuria positive patients (P=0.04). Also, positive inotropic agent usages at the time of leaving the operating room (21.3 vs. 10.1%; P=0.013) and on the 1st day in the intensive care unit (ICU; 29.2 vs. 14.9%; P=0.014), ICU stay day (2.3+/-2 vs. 2.4+/-1.6; P=0.02) and also atrial fibrillation rate (30.3 vs. 17.9%) were higher in Group B (P=0.019). Total hospital stay (7.5+/-2.9 vs. 7.2+/-1.3) was similar. The 30-day mortality was 5.6 times higher (3.4 vs. 0.6%) but statistically not significant (P=0.088) in Group B. The mean follow-up was 30.6+/-16. 2 months in total (30.9+/-16.2 in Group A and 30.1+/-16.5 in Group B). There were 12 late deaths, nine were cardiac, and no differences were detected between groups. CONCLUSIONS: Our findings suggest that postoperative period may be more problematic in diabetic patients with microalbuminuria, but microalbuminuria does not seem to have a major effect on the postoperative course in patients undergoing CABG.

Amiodarone versus digoxin and metoprolol combination for the prevention of postcoronary bypass atrial fibrillation.

OBJECTIVE: This prospective randomized study aims at evaluation and comparison of the prophylactic effects of amiodarone versus digoxin and metoprolol combination in postcoronary bypass atrial fibrillation. METHODS: A total of 241 consecutive patients undergoing elective coronary artery bypass grafting were randomly allocated into three groups. Patients in Group1 (n=77) received metoprolol 100 mg/24 h per oral (P.O.), preoperatively, 2x0.5 mg digoxin intravenously on the operating day and digoxin 0.25 mg P.O.+metoprolol 100 mg P.O. on the first postoperative day until discharge. Patients in Group 2 (n=72) received totally 1200 mg intravenous/24 h amiodarone which the 300 mg - bolus dose/1 h was given as soon as the operation had been finished. On the next day patients were administered 450 mg/24 h amiodarone i.v. and 600 mg/day in three doses P.O. were given until discharge. Group 3 (n=92) was the control group with no antiarrhythmic prophylaxis. RESULTS: Preoperative patient characteristics and operative parameters were similar in three groups. Atrial fibrillation occurred in 13 patients (16.8%) in Group 1, six patients (8.3%) in Group 2 and 31 patients (33.6%) in Group 3. CONCLUSION: Both study groups were effective in the prevention of postcoronary bypass atrial fibrillation with respect to control (P<0.01 in Group 1 and P<0.001 in Group 2).

Midterm angiographic results of off-pump coronary artery bypass grafting.

BACKGROUND: As off-pump coronary artery bypass grafting (OPCAB) has gained wide attention, the quality of surgical revascularization, which showed favorable initial results, is being frequently questioned. This study was undertaken to assess the midterm outcome of beating-heart coronary anastomosis. METHODS: Seventy-four of 315 patients who underwent beating-heart coronary artery bypass grafting via median sternotomy between March 1994 and December 1995 were randomly selected for angiographic assessment. RESULTS: The mean period of control angiography was 50.1 +/- 22.6 months (range, 22 to 83 months). A total of 109 (1.52 +/- 0.55) anastomosis procedures were performed in 74 patients; 38 had single-vessel disease, and 36 had double-vessel disease or disease involving more than 2 vessels. There were no perioperative returns to cardiopulmonary bypass, no major complications, and no hospital deaths. The causes of the need for occlusion included 2 (2.5%) instances of left internal mammary artery-left anterior descending artery anastomosis; 2 (2.5%) of anastomotic site stenosis in left internal mammary artery-left anterior descending artery anastomosis; 7 (19.4%) of saphenous vein graft anastomosis; and 3 (8.3%) of anastomotic site stenosis of saphenous vein graft. Statistical analysis revealed hypercholesterolemia as an independent predictor for graft occlusion (P =.014). The patency rates were not affected by endarterectomy, length of the anastomosed segment, or coronary artery structure. Event-free survival was 73.61% and myocardial infarction-free survival was 91.67%. Reintervention and reoperation rates were 24.3% (18 instances) and 1.4% (1 instance), respectively. CONCLUSIONS: Our results were encouraging for OPCAB, supporting its safety and effectiveness, patency rates and clinical outcome comparable to those of cardiopulmonary bypass, and overall benefits such as reduced hospital costs and postoperative length of stay.