Pregnancy-related myocardial infarction.

INTRODUCTION: The risk of acute myocardial infarction in young women is low, but increases during pregnancy due to the physiological changes in pregnancy, including hypercoagulability. Ischaemic heart disease during pregnancy is not only associated with increased maternal morbidity and mortality, but also with high neonatal complications. Advancing maternal age and other risk factors for cardiovascular diseases may further increase the risk of ischaemic heart disease in young women. METHODS: We searched the coronary angiography database of a Dutch teaching hospital to identify women with acute myocardial infarction who presented during pregnancy or postpartum between 2011 and 2013. RESULTS: We found two cases. Both women were in their early thirties and both suffered from myocardial infarction in the postpartum period. Acute myocardial infarction was due to coronary stenotic occlusion in one patient and due to coronary artery dissection in the other patient. Coronary artery dissection is a relatively frequent cause of myocardial infarction during pregnancy. Both women were treated by percutaneous coronary intervention and survived. CONCLUSION: Physicians should be aware of the increased risk of myocardial infarction when encountering pregnant or postpartum women presenting with chest pain.

In-hospital mortality and three-year survival after repaired acute type A aortic dissection.

Background. The results of acute type A dissection (AAD) surgery in the Netherlands are largely unknown, as was recently stated in a report by the Health Council of the Netherlands. In order to gain more insight into the Dutch situation we investigated predictors of in-hospital mortality of surgically treated AAD patients and assessed threeyear survival.Methods. 104 consecutive patients undergoing surgery for AAD in a 16-year period (1990-2006) were evaluated. Preoperative and intraoperative variables were analysed to identify predictors of early mortality.Results. Preoperative malperfusion (limb ischaemia or mesenteric ischaemia) was present in 15.4%, shock in 18.3%, and 6.7% were operated under cardiac massage. Marfan syndrome was present in four patients and four patients had a bicuspid aortic valve. In-hospital mortality was 22.1%. Seven patients died intraoperatively; other causes of inhospital mortality were major brain damage in ten patients, multiple organ failure in three patients, low cardiac output in two patients and sudden cardiac death in one patient. Multivariate logistic regression revealed preoperative malperfusion (p=0.004) to be the only independent predictor of in-hospital mortality. Three-year survival was 68.8+/-4.7% (including hospital mortality). Hospital survivors had a three-year survival of 88.3+/-3.9%.Conclusion. In-hospital mortality of our patients (22.1%) is comparable with the results of larger case series published in the literature. Prognosis after successful surgical treatment is relatively good with a three-year survival of 88.3% in our series. (Neth Heart J 2009;17:226-31.).

EuroSCORE predicts poor health-related physical functioning six month postcoronary artery bypass graft surgery.

AIM: The objectives of this study are to test whether the European system of cardiac-operative risk evaluation score (EuroSCORE) is associated with preoperative health-related quality of life (HRQoL), and whether it is a predictor of mental and physical health-related quality of life six months after coronary artery bypass grafting (CABG). METHODS: A longitudinal observational study was carried out among 181 patients who underwent CABG. Physical and mental domains of quality of life were measured using SF-36 and risk stratification was estimated using the EuroSCORE. A post hoc test (with Bonferroni correction) was used to determine whether EuroSCORE was associated with preoperative HRQoL, LOS and postoperative rate of complications. Hierarchical regression analysis was performed to explore the associations between EuroSCORE, postoperative events and postoperative HRQoL. RESULTS: EuroSCORE is associated with physical functioning before and after CABG and a higher EuroSCORE is a predictor of poor physical functioning and not a predictor of the mental domains of quality of life, while smoking predicted bodily pain after CABG. Furthermore, readmission within six weeks after discharge was a predictor of poor physical functioning, physical role and general health. Moreover, post hoc tests showed statistically significant and clinically relevant differences in physical functioning between low-risk and high-risk EuroSCORE classes, and between medium and high classes at baseline and six months after CABG. High-risk patients had more perioperative complications and longer lengths of stay, as compared to low-risk patients. CONCLUSION: EuroSCORE is a predictor of poor self-reported physical functioning six months after CABG and is not a predictor of mental functioning.

The many faces of aggressive aortic pathology: Loeys-Dietz syndrome.

BACKGROUND: Loeys-Dietz syndrome (LDS) is a newly recognised disorder of connective tissue which shares overlapping features with Marfan syndrome (MFS) and the vascular type of Ehlers-Danlos syndrome, including aortic root dilatation and skin abnormalities. It is clinically classified into types 1 and 2. LDS type 1 can be recognised by craniofacial characteristics, e.g. hypertelorism, bifid uvula or cleft palate, whereas these are absent in LDS type 2. It is important to recognise LDS because its vascular pathology is aggressive. We describe nine LDS patients from four families, relate their features to published cases, and discuss important aspects of the diagnosis and management of LDS in order to make clinicians aware of this new syndrome. RESULTS: Characteristics found in the majority of these LDS patients were aortic root dilatation, cleft palate and/or a bifid/abnormal uvula. CONCLUSION: Because aortic dissection and rupture in LDS tend to occur at a young age or at aortic root diameters not considered at risk in MFS, and because the vascular pathology can be seen throughout the entire arterial tree, patients should be carefully followed up and aggressive surgical treatment is mandatory. Clinicians must therefore be aware of LDS as a cause of aggressive aortic pathology and that its distinguishing features can sometimes be easily recognised. (Neth Heart J 2008;16:299-304.).

Hybrid approach for complex coronary artery and valve disease: a clinical follow-up study.

BACKGROUND: For patients suffering from complex coronary artery disease (CAD) with or without concomitant valve disease, no evidence is available in the current guidelines to propose a predefined treatment regimen. We sought to assess the clinical impact of an unconventional or extended definition of the hybrid approach that combines percutaneous coronary intervention (PCI) and cardiac surgery in subjects suffering from severe solitary CAD or combined with valve disease. METHODS AND RESULTS: Between July 2002 and August 2004, 18 consecutive patients with complex CAD with or without significant valve disease who qualified for a hybrid approach were enrolled in a clinical follow-up study. Four patients eventually did not complete the proposed interventions. One patient refused treatment after inclusion, one patient died before treatment could be undertaken and two patients died after surgery but before PCI. In the other 14 cases combined treatment was technically successful. After a mean follow-up period of 15alpha5 months two patients had died, one due to sudden cardiac death and one of a noncardiac cause. No other major adverse clinical events were reported. A marked increase in quality of life was reported in those alive. CONCLUSION: Hybrid approach had a favourable long-term outcome in patients with complex cardiovascular disease undergoing successful treatment; however, this was observed at the expense of significant periprocedural mortality in these high-risk subjects. Therefore we believe that hybrid approaches may provide an alternative for selected cases. (Neth Heart J 2007;15:329-4.).

Long-term clinical outcome of patients with diabetes proposed for coronary revascularisation.

BACKGROUND: The optimal method of revascularisation in diabetic patients with coronary artery disease (CAD) remains controversial. It was our aim to evaluate long-term outcome in diabetic patients with CAD in daily practice, in whom an invasive approach was considered. METHODS: A prospective follow-up study of patients with CAD in whom a coronary revascularisation procedure was considered. Follow-up data were obtained on the vital status up to ten years after inclusion. RESULTS: Of the 872 included patients, a total of 107 patients (12%) had diabetes. Patients with diabetes were older and more frequently female. Long-term mortality was higher in diabetics than nondiabetics (36 vs 25%, p = 0.01). This association was observed in both medically treated patients (65 vs 31%, p = 0.01) and in those treated by percutaneous coronary intervention (41 vs 24%, p = 0.02). There was, however, no difference in mortality in diabetes vs nondiabetes patients after coronary artery bypass grafting (24 vs 24%, p = 0.89). Multivariate analysis did not change these findings. CONCLUSION: Diabetic patients with significant CAD had a higher long-term mortality compared with patients without diabetes. In patients with diabetes, survival was highest after coronary artery bypass grafting and appeared to be comparable between diabetic and nondiabetic patients. Complete revascularisation may decrease the influence of diabetes on survival.

Long-term outcome after heart transplantation performed in the University Medical Centre Groningen.

BACKGROUND: Ten years ago, there was a difference of opinion about the suitability of ventilated patients with end-stage cardiac failure for heart transplantation (HTX). Although guidelines at that time qualified mechanical ventilation as a contraindication, we thought those patients could be candidates for HTX. In the same period a number of other patients received a donor heart in our centre. In this article we describe the clinical course and survival after these procedures. METHODS: We performed a retrospective study using our post HTX database. All patients undergoing transplants in our hospital were selected. Patients underwent echocardiography, scintigraphy (MUGA), ergo-spirometry (VO2 peak), blood tests and completed a quality of life questionnaire (SF-36). All tests were completed in the 1st quarter of 2006. RESULTS: Eight patients were identified; three were mechanically ventilated at the time of HTX. All eight patients were treated according to the standard protocol. Repeated surveillance cardiac biopsies were taken. One patient died 3.5 years after HTX due to an acute myocardial infarction. Seven patients, including the three patients on a ventilator at the time of the HTX, are alive, resulting in a survival rate of 88%. The current median survival time is 126 months (range 55 to 184 months). All patients are in good cardiac condition. The SF-36 domains of social functioning and mental health show high scores, the average score of general health and vitality is moderate. CONCLUSION: Survival of our eight transplanted patients after a median period of ten years was 88%, which is at least comparable with data from larger series. This finding suggests that HTX can be performed effectively and safely in a low volume centre. The finding that all three patients on a ventilator prior to HTX are alive is remarkable. It appears that mechanical ventilation is not always an absolute contraindication for HTX.

Stridor and Horner's syndrome, weeks after attempted right subclavian vein cannulation.

A 23-year-old woman presented with renal failure resulting from polycystic kidney disease (PKD) aggravated by tubulo-interstitial nephritis. Emergency haemodialysis was planned, and cannulation of the right subclavian vein was attempted, but failed. During this procedure, inadvertent arterial puncture occurred. Transient mild ischaemia of the right arm, and a transient Horner's syndrome were noted. Seven weeks later she presented with severe stridor with impending respiratory failure necessitating emergency intubation; the right-sided Horner's syndrome had recurred. CT imaging showed a large pseudo-aneurysm of the brachiocephalic artery resulting in severe compression of the trachea. Using a prosthetic graft, the operation for the pseudo-aneurysm was successful; there were mild neurological sequelae. Although her family history was negative, autosomal dominant PKD should be considered, and we discuss the possible role of a pre-existing PKD-associated aneurysm.

Augmentation of abdominal organ perfusion during cardiopulmonary bypass with a novel intra-aortic pulsatile catheter pump.

BACKGROUND: Current pulsatile pumps for cardiopulmonary bypass (CPB) are far from satisfactory because of the poor pulsatility. This study was undertaken to examine the efficiency of a novel pulsatile catheter pump on pulsatility and its effect on abdominal organ perfusion during CPB. METHODS: Twelve pigs weighing 89+/-11 kg were randomly divided into a pulsatile group (n=6) and a non-pulsatile group (n=6). All animals had a CPB for 120 min, aorta clamped for 60 min, temperature down to 32 degrees C, and a perfusion flow of 60 ml/kg/min. In the pulsatile group, a 21 Fr intra-aortic pulsatile catheter, which was connected to a 40 mL membrane pump, was placed in the descending aorta and activated by a balloon pump driver during the first 90 minutes of CPB until aortic declamping. Hemodynamics, organ blood flow, body metabolism, and blood trauma were studied during experiments. RESULTS: Compared with the non-pulsatile group during CPB, the pulsatile group had a higher systolic blood pressure (p<0.01), higher mean arterial pressure (p<0.05), and higher blood flow to the superior mesenteric artery (p<0.05). The hemodynamic energy, indicated by the energy equivalent pressure (EEP) was higher in the gastrointestinal tract and kidney in the pulsatile group (p<0.01, p<0.01). Abdominal organ perfusion status, as indicated by SvO 2 in the inferior vena cava, was higher in the pulsatile group (p<0.05) 30 min after cessation of CPB. Hemolysis indicated by release of free hemoglobin during CPB was similar in the two groups. CONCLUSION: Applying the pulsatile catheter pump in the descending aorta is effective in supplying the pulsatile flow to the abdominal organs and results in improved abdominal organ perfusion during the ischemic phase of CPB.

Influence of hemodilution of plasma proteins on erythrocyte aggregability: an in vivo study in patients undergoing cardiopulmonary bypass.

Erythrocyte aggregation is known to be affected by a number of factors including the concentration of various plasma proteins. This study was performed to examine the in vivo effect of hemodilution of plasma proteins on erythrocyte aggregation in patients undergoing cardiopulmonary bypass (CPB) surgery. Blood samples were taken before, during, and after operation from 40 coronary artery bypass grafting patients who were operated with CPB and concomitant hemodilution (CPB, n=20) and who without (nonCPB, n=20). Erythrocyte aggregation was determined with a LORCA aggregometer, during which all samples were standardized to a hematocrit level of 40%. Results showed that in the CPB patients the aggregation index (AI) dropped to 44% of its preoperative baseline level 5 minutes after the start of hemodilution (from 47.7+/-10.1 to 26.6+/-11.4, p<0.01). Meanwhile, plasma concentration of fibrinogen (Fb) dropped to 55%, haptoglobin to 85%, ceruloplasmin to 55%, and albumin to 67%. In the nonCPB patients, however, there was only a slight drop in AI and the concentrations of plasma proteins during the similar period of time. On postoperative day 1, AI was rebounded to 37.1+/-12.4 in CPB patients compared with 44.3+/-11.7 in nonCPB patients. At baseline, AI was correlated only with Fb. During CPB and hemodilution, AI was correlated not only with Fb but also with haptoglobin and ceruloplasmin. Postoperatively, significant correlationship was found between AI and Fb, CRP, haptoglobin, ceruloplasmin, as well as albumin. These results indicate that hemodilution of plasma proteins significantly reduces the aggregability of erythrocytes in patients undergoing CPB. Besides Fb, other plasma proteins also contribute to AI during the early postoperative period when patients are recovering from CPB surgery.

The practicing physician's current perspective on therapeutic options in coronary artery disease.

Over the past decades the management of patients with stable as well as unstable manifestations of coronary artery disease has evolved in every aspect of routine clinical practice. Modern diagnostic modalities allow reliable and objective assessment of both the anatomical and functional consequences of the early as well as advanced stages of this disease, which remains one of the most important causes of morbidity and mortality worldwide. Pharmacological therapy now includes several classes of drugs with mortality benefits documented by randomised controlled trials. Surgical and percutaneous revascularisation techniques have shown rapid technical improvements and are now applicable in a wide range of clinical conditions. In this paper we will attempt to place the current status of the three therapeutic options for patients with coronary artery disease into perspective. It is important to realise that it is impossible to write a complete overview, a Pubmed search: 'PCI or drug therapy or surgery for coronary artery disease' results in 1,152,117 hits. Therefore, we have chosen the viewpoint of the practicing physician to synthesise this abundance of information in the context of modern clinical practice in a high volume cardiothoracic and cardiological practice.

Gelatin use impairs platelet adhesion during cardiac surgery.

Artificial colloids based on gelatin are used as plasma expander to replace donor blood products. In laboratory experiments, gelatin reduced both the velocity and extend of platelet agglutination by ristocetin, and only the agglutination velocity by polybrene (p < 0.05). Furthermore, gelatin delayed the in-vitro platelet plug formation under shear-stress in the absence of ADP (p < 0.05), whereas gelatin induced no delay in the presence of ADP. Thus, after induction of vWF release from platelets by polybrene or ADP, platelet function was normal. These results indicate that gelatin affects in particular the functionality of plasma-vWF and partly inhibits platelet adhesion. These negative effects of gelatin on hemostasis were demonstrated in two clinical studies during cardiac surgery. In a randomized study of sixty patients undergoing cardiac surgery, gelatin as prime in the heart-lung machine appeared to result in diminished efficacy of aprotinin on hemostasis, whereas it did not affect hemostasis in non-aprotinin patients. An additional retrospective clinical study showed that only high dose of gelatin affected hemostasis. This suggests a limited role of plasma-vWF and a strong back-up mechanism of platelet-vWF in achieving hemostasis.

Activation of fibrinolysis in the pericardial cavity during cardiopulmonary bypass.

The clotting and fibrinolytic systems are activated by tissue factor and by tissue-type plasminogen activator in the pericardial cavity, where the thrombogenicity is greater than that of the surface of modern extracorporeal circuits. This local activation may have consequences for the systemic activation processes during cardiopulmonary bypass. To test this hypothesis, we investigated blood activation by interrupting the blood suction from the pericardial cavity during cardiopulmonary bypass in clinical coronary artery bypass operations. In blood collected in the pericardial cavity, thrombin-antithrombin III complex (p < 0.01), tissue-type plasminogen activator antigen (p < 0.05), fibrinogen degradation products (p < 0.01), and fibrin degradation products (p < 0.01) were significantly higher than in the systemic blood. Plasma heparin was significantly consumed in the pericardial cavity (p < 0.01). Once the pericardial blood was returned to the systemic circulation after resumed suction during cardiopulmonary bypass, thrombin-antithrombin III complex (p < 0.05), fibrinogen degradation products (p < 0.05), and fibrin degradation product (p < 0.05) concentrations increased significantly in the systemic blood. The effects of pericardial tissue on activation of clotting and fibrinolysis were also studied in vitro. When human plasma was incubated for 5 minutes with rabbit pericardium at reduced heparin concentrations, we found significant generation of thrombin (p < 0.05) and plasmin (p < 0.05). If the thrombin inhibitor hirudin was added, plasmin generation was also inhibited (p < 0.05). The results of the clinical and experimental study are in agreement with our hypothesis that tissue factor and tissue-type plasminogen activator accelerate the activation of clotting and sequentially of fibrinolysis under conditions of low heparin concentrations in the pericardial cavity and that this local activation contributes highly to the systemic activation, affecting hemostasis during cardiopulmonary bypass. Topical use of heparin in the pericardial cavity therefore seems indicated to reduce blood activation during cardiopulmonary bypass.

Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients.

From September 1989 to September 1992, the right gastroepiploic artery in combination with one or both internal mammary arteries was used as a graft in 300 patients who underwent coronary artery bypass grafting. The gastroepiploic artery was the primary choice in preference to the saphenous vein. The study comprised 263 men and 37 women, ranging in age from 31 to 77 years (median age 59 years). Thirty-nine patients (13%) underwent previous bypass procedures with autologous vein grafts. In 17 patients (5.7%) the gastroepiploic artery was used as a single graft. In 150 patients (50%) the gastroepiploic artery in conjunction with one internal mammary artery was used (in 6 patients combined with a vein graft). In 133 patients (44.3%) the gastroepiploic artery was used with both internal mammary arteries. Revascularization in nine patients (3%) was combined with another cardiac procedure; three aortic valve replacements, two mitral valve repairs, and four resections of a left ventricular aneurysm. Ten patients died in the hospital (3.3%; 70% confidence limits 2.3% to 4.8%); two of these patients had an infarction in the area revascularized by the gastroepiploic artery. At late follow-up, 0.5 to 39 months (mean 14 months) after the operation, we found no mortality. One patient with an occluded gastroepiploic artery graft underwent reoperation with the use of the right internal mammary artery. One patient underwent percutaneous transluminal coronary angioplasty of the right coronary artery after occlusion of the gastroepiploic artery. Elective recatheterization was done in 88 patients 1 to 25 months after operation (mean 10 months). Graft patency in gastroepiploic artery grafts increased steadily from 77% in the first semester of the study to 95% in the fourth semester and then equaled the patency of the internal mammary artery grafts (97%), which was almost constant during the whole period. We conclude that patency of the gastroepiploic artery was initially related to a "learning curve" but eventually equaled that of the internal mammary artery grafts. Furthermore, the gastroepiploic artery may well be the graft of choice in conjunction with the internal mammary arteries.

Leukocyte depletion results in improved lung function and reduced inflammatory response after cardiac surgery.

Leukocyte depletion during cardiopulmonary bypass has been demonstrated in animal experiments to improve pulmonary function. Conflicting results have been reported, however, with clinical depletion by arterial line filter of leukocytes at the beginning of cardiopulmonary bypass. In this study, we examined whether leukocyte depletion from the residual heart-lung machine blood at the end of cardiopulmonary bypass would improve lung function and reduce the postoperative inflammatory response. Thirty patients undergoing elective heart operations were randomly allocated to a leukocyte-depletion group or a control group. In the leukocyte-depletion group (n = 20), all residual blood (1.2 to 2.1 L) was filtered by leukocyte-removal filters and reinfused after cardiopulmonary bypass, whereas in the control group an identical amount of residual blood after cardiopulmonary bypass was reinfused without filtration (n = 10). Leukocyte depletion removed more than 97% of leukocytes from the retransfused blood (p < 0.01) and significantly reduced circulating leukocytes (p < 0.05) and granulocytes (p < 0.05) compared with the control group. Levels of the inflammatory mediator thromboxane B2 determined at the end of operation (p < 0.05) were significantly lower in the depletion group than in the control group, whereas no statistical differences in interleukin-6 levels were found between the two groups. After operation, pulmonary gas exchange function (arterial oxygen tension at a fraction of inspired oxygen of 0.4) was significantly higher in the leukocyte-depletion group 1 hour after arrival to the intensive care unit (p < 0.05) and after extubation (p < 0.05). There were no statistical differences between the two groups with respect to postoperative circulating platelet levels and blood loss, and no infections were observed during the whole period of hospitalization. These results suggest that leukocyte depletion of the residual heart-lung machine blood improves postoperative lung gas exchange function and is safe for patients who are expected to have a severe inflammatory response after heart operations.

Exclusive use of arterial grafts in coronary artery bypass operations for three-vessel disease: use of both thoracic arteries and the gastroepiploic artery in 256 consecutive patients.

METHODS: From September 1989 to September 1994 we operated on a consecutive group of 256 patients with three-vessel disease in whom we used the right gastroepiploic artery together with both internal thoracic arteries. Vein grafts were not used in these patients. This population consisted of 233 men and 23 women whose ages ranged from 31 to 77 years (mean age 57.8 years). RESULTS: Hospital morbidity and mortality were not directly related to the use of the gastroepiploic artery. Patency of the anastomoses in a subgroup of 56 patients (22%) a mean of 16 months after the operation was 98% for the left internal thoracic artery, 96% for the right internal thoracic artery, and 88% for the gastroepiploic artery. Five-year actuarial survival (including in-hospital deaths) was 95.9% and was related only to age. From discharge until the end of follow-up, two patients had a myocardial infarction, six patients underwent a reintervention procedure, and 18 patients had a return of angina pectoris. CONCLUSION: We conclude that the concomitant use of the gastroepiploic artery with the both internal thoracic arteries has low morbidity and mortality in patients with three-vessel disease operated on by experienced surgeons. At this moment, we have no reason to believe graft patency will deteriorate in the future. On the basis of these results, the knowledge that arteries are to be preferred over veins for coronary bypass grafting, and the absence of a leg incision, we believe this operative technique is superior to the use of venous grafts.

Complement activation in coronary artery bypass grafting patients without cardiopulmonary bypass: the role of tissue injury by surgical incision.

STUDY OBJECTIVES: Complement activation is a trigger in inducing inflammation in patients who undergo coronary artery bypass grafting (CABG) and is usually thought to be induced by the use of cardiopulmonary bypass (CPB). In this study, we examined whether tissue injury caused by chest surgical incision per se contributes to complement activation in CABG patients. DESIGN: Prospective study. SETTING: Thorax center in university hospital. PATIENTS: Twenty-two patients undergoing CABG without CPB were prospectively divided into two groups: a small chest incision via an anterolateral thoracotomy representing a minimized tissue injury (lateral group, n = 8), and a conventional median sternotomy representing a large tissue injury (median group, n = 14). Biochemical markers indicating complement activation as well as systemic inflammatory response were determined before, during, and after the operation. MEASUREMENTS AND RESULTS: Plasma concentrations of complement 3a increased in both the lateral and median groups right after chest incision (p < 0.01 and p < 0.05, respectively) and by the end of operation increased only in the median group (p < 0.01). The terminal complement complex 5b-9 did not increase in the lateral group, but it did increase in the median group both after incision and by the end of the operation (p < 0.05 and p < 0.05, respectively). During surgery, complement 4a did not increase, suggesting that it is the alternative rather than the classic pathway that is involved in complement activation by tissue injury. Postoperatively, interleukin-6 production was greater in the median group (p < 0.01) than the lateral group (p < 0.05), suggesting a more pronounced inflammatory response to a larger chest incision. CONCLUSIONS: Tissue injury caused by surgical incision contributes to complement activation in CABG patients who are operated on without CPB. A small anterolateral thoracotomy is associated with reduced complement activation in comparison with a median sternotomy.

Heparin coating of an extracorporeal circuit partly improves hemostasis after cardiopulmonary bypass.

Heparin coating of an extracorporeal circuit for cardiopulmonary bypass improves the hemocompatibility of the circuit and reduces the inflammatory response of the body. It has not been established, however, that heparin coating also improves postoperative hemostasis. We therefore performed a study in 30 patients who underwent a routine coronary artery bypass graft operation subjected to cardiopulmonary bypass with an uncoated (control) or a heparin-coated extracorporeal circuit (Duraflo II). We found significantly higher plasma levels of heparin in the Duraflo II group. However, we found no significant differences between the two groups with regard to other parameters of activation of the fibrinolytic and coagulation systems and to activation of platelets. Postoperative blood loss and donor blood transfusions were reduced in the Duraflo II group but not to a statistically significant extent. We conclude that heparin coating of an extracorporeal circuit improves anticoagulation but does not significantly reduce platelet activation, fibrinolysis, postoperative blood loss, and donor blood transfusions in routine coronary bypass operations.

Video-assisted minimally invasive coronary operations without cardiopulmonary bypass: a multicenter study.

OBJECTIVE: The need to avoid the risks associated with cardiopulmonary bypass has led to the interest in coronary operations without cardiopulmonary bypass. PATIENTS AND METHODS: From April 1994 to September 1995, 44 patients (mean age 63.3 +/- 10.0 years, range 43 to 83 years) were selected for video-assisted coronary artery bypass grafting without cardiopulmonary bypass through a small anterior thoracotomy. Mean preoperative ejection fraction was 50.7% +/- 13.4% (range 20% to 65%). Four patients had left ventricular dysfunction (ejection fraction below 35%). Thirty patients had stable angina (26 with class 3 angina) and 14 had unstable angina. One had recurrent angina (redo). In all cases a small (3.5 to 11 cm) anterior thoracotomy (43 left and one right) was performed and the harvesting of the left internal thoracic artery was video-assisted by thoracoscopy. RESULTS: The left internal thoracic artery was used in 43 cases to graft the left anterior descending coronary artery; the right thoracic mammary was used in one case to graft the right coronary artery; the radial artery was used in one case to perform a T-graft to the first diagonal and first marginal branches. We recorded one death (2.3%) and one case of postoperative low cardiac output syndrome (2.3%). Perioperative myocardial infarction occurred in two cases (4.5%). We did not record noncardiac complications (cerebrovascular complications, kidney failure, prolonged ventilatory support, or wound complications). Supraventricular and ventricular arrhythmias were never detected. CONCLUSION: According to our experience, video-assisted coronary bypass through a small anterior thoracotomy is a new promising technique that can be considered an alternative in most cases to angioplasty and complementary to conventional coronary operations.

Minimally invasive coronary artery bypass grafting versus coronary angioplasty for isolated type C stenosis of the left anterior descending artery.

BACKGROUND: Isolated stenosis of the left anterior descending coronary artery can be treated with medication, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting. Recently a new treatment has been developed, which is called minimally invasive direct coronary artery bypass grafting. This new treatment is a modification of the conventional bypass operation and is performed through a small anterolateral thoracotomy without cardiopulmonary bypass. METHODS: To compare minimally invasive bypass with angioplasty, we evaluated in-hospital results and 1-year follow-up in 181 consecutive patients with isolated type C stenosis of the left anterior descending coronary artery between January 1995 and July 1996. Of these patients, 71 underwent minimally invasive bypass and 110 angioplasty. Preoperative characteristics were not significantly different between the two groups. RESULTS: In-hospital death, periprocedural myocardial infarction, emergency reoperation by means of conventional coronary bypass grafting, use of an intraaortic balloon pump, and cerebrovascular accidents were not significantly different between the two groups. At 1-year follow-up, survival was not significantly different in the two groups (minimally invasive bypass 95.7% +/- 0.2% vs angioplasty 95.3% +/- 0.2%; p = 0.89), whereas freedom from repeated revascularization was significantly more common in the group undergoing minimally invasive bypass (bypass 96.9% +/- 0.2% vs angioplasty 67.6% +/- 0.5%; p < 0.001). This study shows that the need for repeated revascularization, and therefore the use of health care resources, is significantly less with minimally invasive bypass than with angioplasty in patients with isolated type C stenosis of the left anterior descending coronary artery.