Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function.

BACKGROUND: Conventional coronary artery bypass grafting using cardiopulmonary bypass carries relatively high mortality and morbidity for patients with left ventricular dysfunction. METHODS: Seventy-five patients with ejection fraction less than or equal to 0.35 underwent primary coronary artery bypass grafting without cardiopulmonary bypass between December 1991 and December 1994. Thirty-two patients (43%) had congestive heart failure, 11 (15%) were referred for operation within the first 24 hours of evolving myocardial infarction, and 21 (28%) up to 1 week after acute myocardial infarction. Eighteen patients (24%), 6 of whom were in cardiogenic shock, underwent emergency operations. RESULTS: Mean number of grafts/patient was 1.9 (range, 1 to 4), and internal mammary artery was used in 66 patients (85%). Only 17 patients (23%) received a graft to a circumflex marginal artery. Two patients (2.7%) died perioperatively, and 1 (1.3%) sustained stroke. At mean follow-up of 28 months, 13 patients had died, and angina had returned in 7 (10.5%). One- and four-year actuarial survival was 96% and 73%, respectively. CONCLUSIONS: Coronary artery bypass grafting without cardiopulmonary bypass is a viable alternative to conventional coronary artery bypass grafting particularly for patients with extreme left ventricular dysfunction or those with coexisting risk factors, such as acute myocardial infarction and cardiogenic shock.

Left superior vena cava to the left atrium: do we have to change the traditional approach?

Left superior vena cava (LSVC) to the left atrium is a rare congenital cardiac complex, which may appear as an isolated anomaly, or as part of more complex cardiac anomalies. Traditionally, an intraatrial baffle was the preferred surgical technique. Although this technique has proved reliable and successful, acute ligation and extracardiac repair are simpler and easier solutions, requiring less myocardial ischemic time. We present 3 patients who underwent simple ligation and discuss the literature for other extracardiac options of surgical repair. Our patients had short transient congestion in the left upper part of their body that resolved completely after a few weeks, without further complications. We believe that either acute ligation or extracardiac repair is a much simpler yet effective solution to divert the left caval flow to the lesser circulation.

End-tidal CO2 levels are a reliable indicator of band tightness in pulmonary artery banding.

BACKGROUND: Monitoring of end-tidal CO2 levels, performed routinely nowadays in most operating rooms, is obligatory in our hospital for all anesthesia patients. Levels are dependent on pulmonary blood flow, ventilation, and CO2 content of blood. When ventilation is kept constant, the end-tidal CO2 closely follows pulmonary blood flow. METHODS: Reduction of end-tidal CO2 in the expired air was used to adjust tightness of the pulmonary band in 10 patients with complex cardiac anomalies, all including ventricular septal defect, who underwent pulmonary artery banding. Other parameters were systemic blood pressures and distal pulmonary artery pressures. RESULTS: There were no operative deaths. Average reduction was 3.8 mm Hg (range, 2 to 10 mm Hg; p < 0.001 by paired t test), average increase in systolic blood pressure was 14 mm Hg (range, 4 to 20 mm Hg; p < 0.03 by Wilcoxon sign rank test), distal pulmonary artery pressure was reduced from 56 mm Hg (range, 37 to 79 mm Hg) to 29 mm Hg (range, 20 to 38 mm Hg; p < 0.03 by t test), and postoperative pulmonary artery to systemic pressure ratio averaged 0.36 mm Hg (range, 0.24 to 0.49 mm Hg, difference from preoperative value, p < 0.06). CONCLUSIONS: End-tidal CO2 tension is a simple and convenient, yet highly reliable parameter for adjusting pulmonary artery band tightness.

Predictors of early and overall outcome in coronary artery bypass without cardiopulmonary bypass.

OBJECTIVE: Cardiopulmonary bypass in coronary artery bypass graft operations may adversely affect the outcome especially in high-risk patients. The purpose of this study is to evaluate results of coronary artery bypass performed without cardiopulmonary bypass, in a relatively high-risk cohort, and to identify predictors of unfavorable outcome. METHOD: Three hundred and thirteen (313) patients, 246 (79%) of whom had high-risk conditions, who have a coronary anatomy suitable for coronary artery bypass surgery without cardiopulmonary bypass, underwent this procedure between December 1991 and July 1995. Mean number of grafts/patient was 1.8 (1-5), and only 71 patients (23%) received a graft to the circumflex coronary system. RESULTS: Early unfavorable outcome events included operative mortality (12 patients, 3.8%), nonfatal perioperative myocardial infarction (eight patients, 2.6%), emergency reoperation (three patients, 0.9%), sternal infection (five patients, 1.6%), and nonfatal stroke (two patients, 0.6%). Multivariate analysis revealed angina pectoris class IV (odds ratio 5.4) and age > or = 70 years (odds ratio 5.0) as independent predictors of early mortality. Preoperative risk factors such as repeat coronary artery bypass grafting (50 patients, 16%), ejection fraction < or = 0.35 (85 patients, 27%), acute myocardial infarction (86 patients, 28%), cardiogenic shock (ten patients, 3.2%), chronic renal failure (25 patients, 8%), chronic obstructive pulmonary disease (20 patients, 6%), and peripheral vascular disease (51 patients, 16%) did not increase early mortality. During 33 months of follow-up (range 1-57 months), there were 42 deaths, at least 16 cardiac-related (one and four years actuarial survival of 90% and 76% respectively), and 39 patients (12.5%) in whom angina returned. Calcified aorta (odds ratio 2.6) and old myocardial infarction (odds ratio 1.8) were independent predictors of overall unfavorable events. CONCLUSIONS: Coronary artery bypass grafting without cardiopulmonary bypass can be performed with relatively low operative mortality in certain high-risk subgroups of patients; however, an increased risk of graft occlusion is a potential disadvantage. This procedure should therefore be considered only for patients with suitable coronary anatomy, in whom cardiopulmonary bypass poses a high risk. Although the risk of stroke is relatively low, the procedure is still hazardous for patients aged 70 years and over.

Ascending aortic pseudoaneurysm following coronary bypass in a hemodialysis patient with fever of unknown origin.

A unique patient who developed pseudoaneurysm of the ascending aorta after coronary artery bypass grafting is presented. This case is peculiar due to the presenting symptom being fever of unknown origin. It is the first description of a patient on hemodialysis, who developed ascending aortic pseudoaneurysm.

"King sized" hearts in infants: comparison of cardiac to body mass in ventricular septal defect in various age-groups.

Heart and body weight were reviewed in reports of 223 human cadavers. Of these, 146 were of control (normal) hearts and 77 of hearts with ventricular septal defects. In each case the heart weight as a percentage of body weight was calculated (defined as pathological heart-body ratio). It was observed that under the age of 4 years, monstrous cardiomegalies may reach 3.2% of the total body weight. These "king sized" hearts were not found above the age of 4.