Xenon anaesthesia for patients undergoing off-pump coronary artery bypass graft surgery: a prospective randomized controlled pilot trial.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery carries a high risk for haemodynamic instability and perioperative organ injury. Favourable haemodynamic effects and organ-protective properties could render xenon an attractive anaesthetic for OPCAB surgery. The primary aim of this study was to assess whether xenon anaesthesia for OPCAB surgery is non-inferior to sevoflurane anaesthesia with regard to intraoperative vasopressor requirements. METHODS: Forty-two patients undergoing elective OPCAB surgery were enrolled in this prospective, single-blind, randomized controlled pilot trial. Patients were randomized to either xenon (50-60 vol%) or sevoflurane (1.1-1.4 vol%) anaesthesia. Primary outcome was intraoperative noradrenaline requirements necessary to achieve predefined haemodynamic goals. Secondary outcomes included safety variables such as the occurrence of adverse events (intraoperatively and during a 6-month follow-up after surgery) and the perioperative cardiorespiratory and inflammatory profile. RESULTS: Baseline and intraoperative data did not differ between groups. Xenon was non-inferior to sevoflurane, as xenon patients required significantly less noradrenaline intraoperatively to achieve the predefined haemodynamic goals {geometric mean 428 [95% confidence interval (CI) 312, 588] vs 1702 [1267, 2285] µg, P<0.0001}. No differences were found for safety. Significantly more sevoflurane patients developed postoperative delirium (POD) (hazard ratio 4.2, P=0.044). The average arterial pressure was lower in the sevoflurane group {median75 [interquartile range (IQR) 6] vs 72 [4] mmHg, P=0.002}. No differences were found for other haemodynamic parameters, the respiratory profile and the perioperative release of inflammatory cytokines, troponin T, serum protein S-100ß and erythropoietin. CONCLUSIONS: Compared with sevoflurane, xenon anaesthesia allows a significant reduction in vasopressor administration in OPCAB surgery. Moreover, xenon anaesthesia was associated with a lower risk for POD, a finding that has to be confirmed in larger studies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01757106) and EudraCT (2012-002316-12).

Cross-reactivity of a new food ingredient, dun pea, with legumes, and risk of anaphylaxis in legume allergic children.

BACKGROUND: Legume allergy is the fifth food allergy in Europe. The dun pea (Pisum sativum sativum var. arvense), a pea belonging to the same subspecies as green pea, has been recently introduced as an ingredient in the human food industry. The aims of this study were to evaluate the cross-reactivity between dun pea and other legumes and to search for modification of allergenicity induced by food technologies. METHODS: A series of 36 patients with legume and/or peanut allergy was studied. They underwent skin tests to peanut and a panel of legumes including dun pea. Specific IgE to dun pea and cross-reactivity to peanut allergens, particularly to Ara h 1, were evaluated by ELISA. Proteins and allergens of different pea extracts were studied by SDS-PAGE and immunoblots. RESULTS: In France and Belgium, 7.7% of severe food anaphylaxis cases were due to legumes. Patients with isolated legume allergy had positive prick tests to dun pea, whereas patients with isolated peanut allergy had negative prick tests. Cross-reactivity between sIgE to peanut and dun pea was observed, and more frequently than expected (96%) peanut-allergic patients with legume sensitization or allergy had sIgE to Ara h 1. Analysis of dun pea allergens suggested that protein epitopes were presented differently in dun pea seeds, isolate and flour. CONCLUSIONS: This study identifies, for the first time, a risk of dun pea allergy in legume-allergic patients and in a subset of peanut-allergic patients.

An apple a day ... chronic glossitis in a 4-year-old boy.

We report a case of chronic glossitis in a 4-year-old boy due to scurvy. The boy showed up in our department with a patchy depapillated tongue. A detailed dietary history revealed an unbalanced diet without any fruit or vegetable. The biological investigations showed a low serum ascorbic acid. The boy was treated by oral ascorbic acid during 15 days. The glossitis improved within one week and serum levels of vitamin C returned to the normal range. In industrial countries, scurvy became a rare disease in healthy children. However, since a few years, cases are reported in children and teenagers with unbalanced diet coming from economically favoured families. These extreme cases are one of the signs of a more general deterioration of dietary habits in paediatric populations in our societies. This emphasizes the importance of effective nutritional education programs aimed towards both parents and children.

The value of pulse pressure and stroke volume variation as predictors of fluid responsiveness during open chest surgery.

SUMMARY: We investigated the ability of pulse pressure variation and stroke volume variation to predict fluid responsiveness during mechanical ventilation in patients undergoing open chest surgery by comparing their respective correlations with cardiac output changes induced by leg elevation. Serial leg elevation manoeuvres were performed before and after sternotomy in 15 patients scheduled for elective off-pump coronary bypass surgery. Under closed chest conditions, both pulse pressure variation and stroke volume variation correlated well with the induced cardiac output changes (r = 0.856, p = 0.002 and r = 0.897, p = 0.0012, respectively). These correlations were lost for both parameters following sternotomy. Our data show that pulse pressure variation and stroke volume variation are valid predictors of fluid responsiveness under closed chest conditions but that this property no longer holds when the chest is open.

[Coronary artery bypass surgery: methods of performance monitoring and quality control]. / Qualitätskontrolle der Koronaren Bypasschirurgie.

The strength of coronary bypass operations depends on the preservation of their benefits regarding freedom of symptoms, quality of life and survival, over decades. Significant variability of the results of an operative intervention according to the hospital or the operating surgeon is considered a weakness in the procedure. The external quality insurance tries to reach a transparent service providing market through hospital ranking comparability. Widely available information and competition will promote the improvement of the whole quality. The structured dialog acts as a control instrument for the BQS (Federal Quality Insurance). It is launched in case of deviations from the standard references or statistically significant differences between the results of the operations in any hospital and the average notational results. In comparison to the external control the hospital internal control has greater ability to reach a medically useful statement regarding the results of the treatment and to correct the mistakes in time. An online information portal based on a departmental databank (DataWarehouse, DataMart) is an attractive solution for the physician in order to get transparently and timely informed about the variability in the performance.The individual surgeon significantly influences the short- and long-term treatment results. Accordingly, selection, targeted training and performance measurements are necessary.Strict risk management and failure analysis of individual cases are included in the methods of internal quality control aiming to identify and correct the inadequacies in the system and the course of treatment. According to the international as well as our own experience, at least 30% of the mortalities after bypass operations are avoidable. A functioning quality control is especially important in minimally invasive interventions because they are often technically more demanding in comparison to the conventional procedures. In the field of OPCAB surgery, the special advantages of the procedure can be utilised to reach a nearly complete avoidance of postoperative stroke through combining the procedure with aorta no-touch technique. The long-term success of the bypass operation depends on the type of bypass material in additions to many other factors. Both internal mammary arteries are considered the most durable.Using an operation preparation check contributes to the operative success.

[Should we avoid cardiopulmonary bypass with diabetic patients?]. / Bypassoperationen bei Diabetikern--mit oder ohne HLM?

In the peri-operative and post-operative course of coronary bypass operations, the diabetic patient is susceptible to complications that cause morbidity and mortality. Morbidity might best be conceptualized as the cumulative effect of the diabetic patient chronically at risk and a variety of surgically related insults, including surgical stress, anaesthesia, hypo- and hypertension, anaemia, dysrhythmias, de- or hyperhydration and cardiopulmonary bypass (CPB) that exceed the compensatory capacities of the patient. Because all these factors for adverse outcome coexist, it becomes difficult to determine which ones are most important. However, it is reasonable that, in the presence of generalized atherosclerosis affecting the aorta ascendens, carotids and the cerebral arteries, the interaction of CPB-associated embolization, hypoperfusion and inflammation may cause neurologic morbidity. Many physiologic alterations (such as non-pulsatile perfusion and hemodilution) occur during CPB and may worsen renal dysfunction in patients with diabetic nephropathy. Pulmonary dysfunctions, associated with diabetic microangiopathy, could be unmasked by atelectasis, capillary leak and other pathophysiological conditions developing after the use of extracorporeal circulation. Actually, there is evidence that with the avoidance of CBP and the use of adequate OPCAB (Off Pump Coronary Artery Bypass) techniques, by experienced teams, the incidences of neurological, renal and pulmonary complications decrease, in high-risk patients, e. g. diabetics, as well as in unselected cohorts. Because it is not possible to identify confidently those patients who are at risk for CPB-associated complications, we use a strategy where all CABG (Coronary Artery Bypass Grafting) are performed in OPCAB technique. The total OPCAB approach will in addition ascertain the development of organizational OPCAB routines and expertise. The process of re-engineering the unit towards total OPCAB needs systematic training and re-training of cardiac surgeons by surgeons, experienced in both, OPCAB surgery and knowledge transfer, according to the principles of continuing medical education (CME). Thus, the chances of the OPCAB technique improving the outcome of diabetic patients can be fully realized.

Evaluation of a new continuous cardiac output monitor in off-pump coronary artery surgery.

We evaluated a new, ultra-fast response continuous cardiac output monitor in 34 adult patients undergoing off-pump coronary artery bypass graft surgery. Cardiac output was measured with the TruCCOMS continuous cardiac output monitor (Aortech International plc, Lanarkshire, UK), using triplicate cold bolus thermodilution as the criterion standard, at fixed time points during surgery and during dobutamine infusion. The two techniques were compared using linear regression and Bland-Altman analysis. Overall, the study device displayed a bias of 0.4 l.min(-1) with limits of agreement of +2.5 l.min(-1) and -1.7 l.min(-1). The study device failed to detect the change in cardiac output caused by dobutamine accurately (y = 0.18x + 0.45; r(2) = 0.13), with an error linearly related to the magnitude of the change measured. We conclude that the device's failure to detect changes in cardiac output could be a major limitation in its clinical use in its current form.

Initial experiences with the Impella device in patients with cardiogenic shock - Impella support for cardiogenic shock.

BACKGROUND: We planned a study to assess the safety, feasibility, and efficacy of the Impella micro-axial blood pump in patients with cardiogenic shock. METHODS: From January 2001 to September 2002 inclusive, 16 patients in cardiogenic shock (maximal inotropic support and with IABP in 11 cases) underwent left ventricle unloading with the Impella pump. 6 were placed via the femoral artery (patients in the coronary care unit) and 10 directly through the aorta (postcardiotomy heart failure). In three patients, the device was used in combination with ECMO. Mean age was 60 years (range 43 - 75), 11 were male. RESULTS: A stable pump flow of 4.24 +/- 0.28 l/min was reached (3.3 +/- 1.9 l/min in patients with ECMO and Impella). Mean blood pressure before Impella) support was 57.4 +/- 13 mmHg, which increased to 74.9 +/- 13 mmHg after 6 hours and 80.6 +/- 17 mmHg (p = 0.003) after 24 hours. Cardiac output increased from 4.1 +/- 1.3 l/min to 5.5 +/- 1.3 (p = 0.003) and 5.9 +/-1.9 l/min (p = 0.01) at 6 and 24 hours. Mean pulmonary wedge pressure decreased from 29 +/- 10 mmHg to 17 +/- 5 mmHg and 18 +/- 7 mmHg at 6 (p = 0.04) and 24 hours. Blood lactate levels decreased significantly after 6 hours of support (from 2.7 +/- 1 to 1.3 +/- 0.5 mmol/l, p = 0.004). Device-related complications included three sensor failures (no clinical action), one pump displacement (replacement) and six incidences of haemolysis (peak free plasma haemoglobin > 100 mg/dl, no clinical action). Eleven patients (68 %) were weaned, six (37 %) survived. CONCLUSIONS: Left ventricular unloading with the Impella pump via the transthoracic or femoral approach is feasible and safe. Support led to a decrease in pulmonary capillary wedge pressure, increase in cardiac output and mean blood pressure, and improved organ perfusion in patients with severe cardiogenic shock.

Food safety of allergic patients in hospitals: implementation of a quality strategy to ensure correct management.

Food allergy could affect up to 8% of children. Four cases of food anaphylaxis in hospitalized children are reported, pointing to the need of food allergenic safety procedures in hospital settings. The implementation of the operating procedure in hospital food production units (HFPU) of Nancy University Hospital is described. The dietetics Department developed on hypoallergenic diet and specific avoidance diets. Dieticians within HFPU managed the choice of starting materials, the circuit organization in order to avoid any risk of contamination during preparation and cooking of food, product traceability, and trained the staff of HFPU. Within the care units physicians, dieticians, nurses, hospital workers are involved in meal management. A diet monitoring sheet is integrated into the patient's nursing file and enables the dietician to validate the diet in the computer, the nurses to display the patient's diet on the schedule on the wall in their office. The hospital workers finally use a tray form indicating the patient's identity, his/her diet and the menu of the day. Such a procedure absolutely secures the whole circuit and specifies the responsibilities of each person, whilst ensuring effective cooperation between all partners. Since 1999, the implementation of this multi-step strategy has prevented from any further reaction in a department specialized for food allergies in children and in adults. As setting up food allergenic safety in hospitals in not addressed adequately in the European directives, it's judicious to draw attention of hospital catering managers and hospital canteen staff to this necessity.

Single centre, single domain validation of the EuroSCORE on a consecutive sample of primary and repeat CABG.

OBJECTIVES: Intra- and interdepartmental benchmarking require scoring systems with excellent performance on several properties: discrimination (resolution), reliability (calibration) and stability over the complete spectrum of peri-procedural risk. This single centre, single domain study validates the European system for cardiac operative risk evaluation (EuroSCORE) on an independent sample of primary and repeat coronary artery bypass grafting (CABG) patients and will evaluate these different properties. METHODS: The study population is a consecutive series of 2051 isolated primary and repeat CABG patients, inclusive of patients in cardiogenic shock or resuscitation, operated on in a single institution from January 1997 to July 2000. The age of the patients was 66+/-9 years, 77% were males and 7% were repeat procedures. The EuroSCORE was 5.0+/-3%, with a range from 0 to 22. The studied event was in-hospital death, defined as mortality during hospital stay, which was unlimited in time and included a stay in a secondary hospital without discharge home. RESULTS: The EuroSCORE predicted 102 deaths versus 81 deaths observed (P=0.14, Fisher exact test). The EuroSCORE described only 20% of the variance of in-hospital mortality. The EuroSCORE created an area under the receiver operating characteristic curve of 0.83+/-0.03. The highest discriminative accuracy was obtained with 8% EuroSCORE risk (only 64% sensitivity and 87% specificity). Further exploration identified an over score in the EuroSCORE range 0-8 (57%, P<0.0001). There was an equal score (-2%, P=1) in the range 9-11, but an under score in the range 12-22 (-133%, P=0.003). CONCLUSIONS: On the condition that these single centre results could be extended to any European cardiac surgery centre, it can be concluded that the overall acceptable performance of the EuroSCORE is the result of an over score in the lower risk and insufficient correction in the higher risk spectrum. The EuroSCORE is probably refined enough for improved informed consent versus aggregated results but should only be used for inter-institutional benchmarking with great caution, preferably below the 12% risk pivot.

The challenge of departmental quality control in the reengineering towards off-pump coronary artery bypass grafting.

OBJECTIVE: Off pump coronary surgery is a major reengineering effort of the surgical systems. There are no perfect tools available to guide every centre in the confrontation with the complete spectrum of risk and the limited number of events. This study analyses the use of a hospital mortality risk-stratifying system in the complete shift towards off-pump CABG. METHODS: All 535 off-pump CABG patients from January 1997 till September 2000 underwent a comparison of their hospital mortality versus the EuroSCORE predictions. The mean risk predicted by the EuroSCORE was 4.5+/-3% (range 0-14) and the mean age was 65+/-10 years (range 36-89). The series includes 23 repeat procedures, also 77 patients with per oral or insulin-treated diabetes. The number of distal anastomoses was 2.5+/-1 and of arterial grafts 1.3+/-0.6. RESULTS: The observed hospital mortality was 15 patients, 2.8% (Fisher exact test P=0.19 versus the EuroSCORE). The 1 and 3 month Kaplan-Meier survival, irrespective from hospital discharge, was 97.4+/-0.7 and 97.2+/-0.7%, respectively. A cumulative risk-adjusted mortality plot is constructed. The area under the ROC curve was 0.886. A stepwise sampling of patients according to increasing risk identified the difference between the EuroSCORE-predicted and observed hospital mortality for the complete spectrum of risk. The P value of this difference was 0.06 for the grouping including all patients from 0-5% risk (78% reduction), 0.04 for the grouping 0-8% risk (61% reduction), and 0.05 for the grouping 0-11% risk (52% reduction of risk). The loss of statistical significant difference was due to the inclusion of the patients at extremely high risk. CONCLUSION: A hospital mortality risk-stratifying system can provide guidance but different and in depth approaches are mandatory to improve the insight, certainly in the presence of a large spectrum of risk.

[Towards simplified cesarean section?]. / Vers une simplification de l'opération césarienne?

In the past few years, many international publications have reported important improvements in the cesarean section procedure. Considering these improvements, M STARK suggests a new technique for the cesarean section which is called <> (=ML). To assess feasibility and efficiency of this technique the authors conducted a prospective randomised study for 4 months including all cesarean sections and compared the ML technique with the classical Pfannenstiel are. The following criteria were noted for each woman. Results showed the superiority of the M.L. technique especially with regard to the length of duration of the post-operative fever and the parietal blood collection, where difference is significant. Regarding the blood loss rate, the post-operation pain, the delay before gas and the duration of the hospitalisation period the M.L. technique seems to be better although the difference is not very significant statistically. Following this study and the international literature survey, authors conclude that the M. L technique is so much better than the pfannenstiel technique that it must be used throughout daily obstetrical practice.

Mechanical support with microaxial blood pumps for postcardiotomy left ventricular failure: can outcome be predicted?

OBJECTIVE: We sought to identify the indications of mechanical support in postcardiotomy left ventricular failure in patients who are unable to undergo transplantation. METHODS: From 1989 through 1997, 61 patients with postcardiotomy left ventricular failure beyond intra-aortic balloon pumping were assisted with the Hemopump cardiac assist system (Medtronic, Minneapolis, Minn). Their mean age was 64 +/- 8 years. Comorbidity was prevalent; 47% underwent cardiac massage before pump support, and evolving myocardial infarction was diagnosed in 43% before surgery. Multivariable logistic regression of data known at the moment of pump insertion was performed to identify the risk factors for mortality. RESULTS: Sixty-five percent of the patients were weaned from the device, but only 30% were discharged home. Cardiac index evolution during the first hours after pump insertion (P <.001) is the only independent predictor for possibility to wean from the device in the multivariable analysis. Acute renal failure is the only variable retained in the model for 90-day mortality. Device-related complications were far more frequent with the femoral (54%) than with the transthoracic (6%) cannula. Only 13% of the patients had bleeding complications. CONCLUSIONS: One third of the patients with postcardiotomy heart failure refractory to use of the intra-aortic balloon pump can be saved with the use of an endovascular axial flow pump. It is impossible to predict lethal outcome on preoperative data alone. The early hemodynamic response to support seems to be related to functional recovery of the heart and subsequent weaning from the device.

Micropumps to support the heart during CABG.

OBJECTIVE: To show the effect of myocardial support by micropumps during beating heart CABG for triple vessel disease. METHODS: In 12 sheep, three coronary arteries (LAD, intermediate branch and circumflex) were consecutively occluded for 10 min. The animals were divided in two groups: group 1 without support (n=6) and group 2 with biventricular support of intravascular micropumps. The pumps (diameter 6.4 mm) were placed through peripheral access (femoral artery and jugular vein) and advanced under fluoroscopic guidance. The hemodynamic evolution was analyzed during the procedure and 2 h of reperfusion. Myocardial flow was assessed by colored microspheres. Differences between groups were analyzed by ANOVA for repeated measurements and post-hoc testing in case of significance. RESULTS: All of the pump-supported animals survived the procedure, 1 of the control animals died of resistant ventricular fibrillation. At the end of the reperfusion period, the hemodynamic performance and myocardial contractility was significantly better in the pump-supported group (cardiac output: 2.4+/-0.9 vs. 3.3+/-0.9 l/min, P=0.0192; mean arterial blood pressure: 51+/-23 vs. 73+/-9 mmHg, P=0. 036; first derivative of the left ventricular pressure: 561+/-271 vs. 947+/-316 mmHg/s, P=0.0074). After the procedure, subendocardial blood flow was significantly better in all areas of the left ventricle in group 2 (0.935+/-0.427 ml/min per g vs. 0.409+/-0.183 ml/min per g in group 1; P=0.0366). CONCLUSION: The supported heart is more resistant to repetitive local ischemia. Support by microaxial pumps can make beating heart surgery safer and applicable for more complex cases.

Closing the loop: optimizing physicians' operational and strategic behavior.

Clinical databases are essential elements in optimizing medical care. They are no finality by themselves, but essential elements in the generation of knowledge. Optimal medical care starts with optimal care based on existing knowledge. This care continues with the registration of the variability in morbidity, comorbidity, and therapy, but also the registration of the early and late outcome. This should then allow the generation of structured inferences based on this registration and the closure of the loop, by treating patients according to this newly created evidence.

The optimal mode of coronary revascularization for diabetics. A risk-adjusted long-term study comparing coronary angioplasty and coronary bypass surgery.

AIMS: Some recent studies have reported-superior outcomes for diabetic patients following coronary bypass surgery compared with coronary angioplasty. However, the available data are conflicting, are based on relatively small numbers of diabetic patients, and have limited duration of follow-up. The aims of this study were to compare risk adjusted long-term survival in diabetic patients following first-time revascularization via either coronary bypass surgery or coronary angioplasty; and, to identify variables independently associated with mortality. METHODS AND RESULTS: This was a two centre database project involving 15809 patients undergoing either coronary angioplasty or coronary bypass surgery as their initial revascularization procedure. Diabetes was present in 1938 (12%). Mean follow-up was 4.6+/-2.7 years for angioplasty and 6.6+/-4.3 years surgery diabetic patients. Multivariable time-related analyses in the hazard function domain for death were performed. Overall ten-year survival for pharmacologically treated diabetics was better after coronary bypass surgery (60%) than angioplasty (46%, <0.0001). However, the risk-adjusted survival advantage conferred by bypass surgery over angioplasty was strongest for patients receiving oral agents for diabetic control (75% vs 62%) and less impressive for diet (84% vs 81%) and insulin-treated diabetics (63% vs 64%). The major factors independently associated with worse outcome after angioplasty were incomplete revascularization, and the use of a sulfonylurea agent. The use of the left internal mammary graft improved survival in surgical patients. CONCLUSIONS: In general, diabetic patients had better long-term survival after bypass surgery than angioplasty. Incomplete revascularization and sulfonylurea therapy worsened outcome after angioplasty, and use of the left internal mammary improved outcome after bypass surgery.

First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting.

OBJECTIVE: To study the first reintervention for ischemic heart disease anytime after coronary artery bypass grafting (CABG) and the variables that drive its need or bias its occurrence. Reintervention is defined as an isolated or combined repeat surgical or cardiological procedure for ischemic heart disease. METHODS: A consecutive series of 9600 CABG patients (1971-1992) were followed for up to 20 years (99.9% complete). A multivariable time-related analysis was performed. RESULTS: The 1-, 10- and 15-year freedom from reintervention was 99, 89 and 72% respectively. A three-phase hazard function was identified. Patient variables influencing early freedom included anginal instability, completeness of revascularization and institutional variables. Late freedom was influenced importantly by demographic variables, cardiac and non-cardiac comorbidity and extensive arterial grafting. The 1-month and 10-year survival after reintervention was 95 and 73%. The 1- and 10-year freedom from angina after reintervention was 74 and 32%. CONCLUSION: Reinterventions for ischemic heart disease by interventional cardiology or surgery are rather infrequent in the first decade after CABG but nearly half the patients surviving their second decade undergo one. The increased reintervention rate, apparent after 1985 did not go parallel with improved late post-CABG survival. Older age and the presence of multiple arterial grafts seem to reduce but also to bias the event. The very good survival, only when return of angina is present, suggests a more restrictive differential therapy approach, certainly in the presence of a well functioning arterial graft to the antero-septal region and where the co-morbidity might induce a high reinterventional survival cost.

Is return of angina after coronary artery bypass grafting immutable, can it be delayed, and is it important?

BACKGROUND: Because survival after either an operation or angioplasty is similar across a wide spectrum of coronary patients, lasting symptom relief assumes high priority. OBJECTIVES: The objectives of this observational clinical study were (1) to determine whether the return of angina is immutable; (2) to identify factors that might delay its return, and (3) to evaluate whether its return is predictive of subsequent adverse events. METHODS: The return of angina of any degree of severity and morbid events subsequent to its return were studied by multivariable time-related analyses in a consecutive series of 9600 patients who were undergoing primary isolated coronary bypass operations between 1971 and 1992. RESULTS: The freedom rate from return of angina was 94%, 82%, 61% and 38% at 1, 5, 10, and 15 years. Increased modest risk of early return of angina was associated with preoperative demographic, symptom, coronary and vascular disease variables but reduced by more extensive arterial grafting. The ever-increasing risk of late return of angina was associated with demographic, symptomatic, left ventricular function, and coronary disease variables and was related strongly to comorbidity but was weakly reduced by controllable surgical variables. After the return of angina, 10-year freedom rate from infarct and survival was 71% and 68% respectively. CONCLUSIONS: (1) The risk of angina return increases relentlessly after operation, so it is likely immutable. (2) Delay of late angina return by use of arterial grafting is clinically trivial; control of noncardiac comorbidity may be more effective. (3) Fortunately, the return of angina after coronary artery bypass grafting has minimal impact on survival and is not predictive of imminent infarct.

Does arterial revascularization decrease the risk of infarction after coronary artery bypass grafting?

BACKGROUND: This study sought to determine whether extensive arterial grafting reduces the prevalence and consequences of infarct after coronary artery bypass grafting. METHODS: Post-primary coronary artery bypass grafting infarcts and time-related events thereafter were identified by 99.9% complete follow-up of 9,600 patients (1971 to 1992). The contribution of arterial grafting to freedom from infarct was assessed by multivariable hazard function analysis to adjust for other risk factors. RESULTS: Unadjusted 1-month and 10-year freedom from infarction was 97% and 86%. By multivariable analysis, arterial grafting lowered the prevalence of periprocedural (p = 0.005), intermediate term (p = 0.007 and 0.006), and late infarction (arterial grafting to the left anterior descending coronary artery, p = 0.0006). Unadjusted survival after first infarct after coronary artery bypass grafting was 74% and 52% at 1 and 10 years; arterial grafting improved 10-year survival from 48% to 59% (p = 0.002). An additional benefit or cost of extending arterial grafting (n = 1,727) beyond a single one could not be identified (p > 0.1). CONCLUSIONS: Arterial conduits, particularly to the left anterior descending coronary artery, should be used for coronary artery bypass grafting to reduce early and late myocardial infarction and its consequences. However, use of more than a single arterial graft appears to confer no additional benefit.