[Off-pump coronary bypass grafting in patient with left main occlusion and 75% stenosis of right coronary artery]. / Off-pump koronarni bajpas kod pacijenta s okluzijom glavnog stabla lijeve i 75% stenozom desne koronarne arterije.

Patients with significant stenosis (>50%) of the left main coronary artery (LM) are considered high risk for coronary artery bypass grafting (CABG). LM disease is mainly considered a relative contraindication for off pump coronary artery bypass grafting (OPCAB) because of the reduced tolerancy of hamodynamic disturbances which occurs during mobilisation and exposition of the heart, necessary for this type of operations. The aim of the study is to show feasibility of OPCAB for patient with occlusion of the LM and 75% stenosis of the right coronary artery. Operation was carried out through median sternotomy, LIMA stitch was used for the exposure, CTS stabilisator was used for local myocardial stabilisation, intracoronary shunt was inserted intraluminary. Three aortocoronary bypasses were created, operation passed without any hamodynamic instability. Main peri and postoperative results: total length of the operation: 265 min; time on respirator: 1 hour; total blood drainage on chest tubes: 532 ml; transfused blood: 0 ml; time in the intensive care unit: 1 day; total hospitalisation time: 7 days. This case review suggest that OPCAB is feasible and safe in the treatment of patients with LM occlusion and significant stenosis of RCA.

[Intraoperative quality control in the coronary artery bypass grafting]. / Intraoperativna kontrola kvaliteta koronarnih arterijskih bajpas graftova.

INTRODUCTION: The issue of the quality of bypass grafts, which appeared to be a key fact in the coronary artery bypass grafting (CABG), was raised with the popularization of the operations performed without the use of cardiopulmonary bypass (CPB). Among handful methods used in the past that were abundant in defects, Transit time flow measurement (TTFM) has recently stood out for its good features. The objective of the paper is: to compare main peri and postoperative results of operations with and without CPB; to establish total number of the bypass grafts revised on the basis of TTFM results in both groups of the examinees; to evaluate sensitivity, specificity, predictive rate and accuracy of TTFM with regards to the intraoperative coronary angiography (golden standard). MATERIAL AND METHODS: Study was done in the period between 01.07.2002 and 30.06.2004 in two centers. In the Cardiovascular Clinic, University Clinical Centre Tuzla, 150 examinees were operated on without the use of CPB (group A) and compared with 150 examinees operated on with the use of CPB (group B). Main peri and postoperative results and bypass grafts revised on the basis of TTFM findings were analyzed. In the Interventional Center, Rikshospitalet, Oslo, 70 examinees underwent CABG without the use of CPB. The TTFM result of these examinees was compared with the intraoperative angiography result for each bypass graft. THE RESULTS: Time spent on the respirator was significantly less in the examinees who underwent CABG without the use of CPB (p=0.001) as well as the amount of compensated blood (p=0.034) and the hospitalization duration (p=0.004). The frequency of the bypass grafts revisions based on the TTFM results was higher in the group A but with no statistical importance when compared with the group B (p=0.657). Comparative analysis of the TTFM grades and intraoperative angiographies grades indicated that TTFM has sensitivity 0.953, specificity 1.000, positive predictive rate 1.000, negative predictive rate 0.743, and accuracy 0.958 in relation to the intraoperative anglography. CONCLUSION: TTFM is a valid method for intraoperative quality control of coronary artery bypass grafts. Intraoperative quality control would not just improve the operative results, but also the cost-effectiveness of CABG.

[Beating heart surgery in the treatment of stenoses of the main branch of the left coronary artery]. / Operacije na kucajucem srcu u tretmanu stenoze glavnog stabla lijeve koronarne arterije.

This study reviewed the early experience with off-pump coronary artery bypass surgery in treatment of patients with severe left main coronary artery stenosis. From May 2002-December 2003, 75 patients with significant left main coronary artery stenosis (> or = 50%) underwent coronary artery bypass grafting. 35 patients were operated without the use of cardiopulmonary bypass (OPCAB) and compared with 40 patients operated with the use of cardiopulmonary bypass (ONCAB). Mean age, ejection fraction and EUROSCORE were similar in both groups. Average grafts per patients was also similar (OPCAB 3.0 vs. ONCAB 3.2). The incubation time (3.1 vs. 5.8 hours), blood loss (445 vs. 610 ml) and hospital stay (6.8 vs. 8.1 days) were less in OPCAB group. There was no mortality in OPCAB group whereas 2 patients (5.0%) died in ONCAB group. Our early experience suggests that off-pump coronary artery bypass surgery is effective in treatment of patient with severe left main coronary artery stenosis and has advantages compare to operations with the use of cardiopulmonary bypass.

Conversions in off-pump coronary surgery.

METHODS: There have been 784 coronary artery bypass grafting (CABG) procedures performed at a new center for treating cardiovascular disease in Tuzla, Bosnia and Herzegovina, and the surgical team has been fully trained in offpump coronary artery bypass (OPCAB) surgery. All surgical patients were considered for on-pump CABG (ONCAB) and OPCAB surgical procedures. Minimally invasive direct coronary artery bypass grafting and robotic procedures were done as OPCAB. For multivessel median sternotomy cases, the selection criteria were arbitrary (approximately 50% were performed as ONCAB for perfusionist training). Patients who were scheduled for and began their operations as OPCAB but who were then placed on cardiopulmonary bypass during the surgical procedure were counted as conversions. The outcomes of converted patients were studied and are the subject of this report. RESULTS: Of the 784 CABG procedures, 391 (49.6%) were scheduled and performed as ONCAB operations; 357 (45.5%) were performed as OPCAB; and 36 (9.2% of the originally scheduled OPCAB patients or 4.6% of the total number of CABG surgeries) were originally scheduled as OPCAB operations but were converted to ONCAB. Reasons for conversions were hemodynamic instability (21 patients), difficult revision of grafts (8), ventricular fibrillation (5), and poor native vessel (2). Outcomes of patients undergoing conversions were analyzed with respect to the conversion cause. When the cause of the conversion was mild-to-moderate hemodynamic instability or difficult graft revision (n = 27), no adverse ischemic effects were seen; however, when the cause of conversion was severe hemodynamic instability, ventricular fibrillation, or cardiac arrest (n = 9), 6 patients (66.6%) had severe ischemic complications involving the central nervous system or the myocardium. DISCUSSION: Myocardial ischemia must be monitored and treated aggressively in OPCAB surgery. In patients with mild hemodynamic instability, conversion did not adversely affect outcome. In patients with severe hemodynamic compromise and cardiac arrest, serious complications of cerebral and myocardial ischemia were observed. The appropriate timing of conversion is essential.

[Coronary artery bypass grafting without use of cardiopulmonary bypass]. / Koronarno arterijsko bajpas graftiranje bez upotrebe kardiopulmonalnog bajpasa.

Although it is possible to find a number of comparative studies in the world literature discussing the results of coronary artery bypass surgery (CABG) with and without cardiopulmonary bypass (CPB), until now such analysis has not been made in Bosnia and Herzegovina. The main aim of this scientific work was to compare morbidity and mortality, need for blood transfusions, length of stay in the intensive care unit and total length of hospitalisation in two groups of patients operated with these methods. One hundred and four patients with coronary artery disease operated in Cardiovascular Clinic Tuzla, from September, 1998 to September 2002 divided in two groups, were included in this study. There were 52 patients in the first group operated with CPB and 52 patients in the second group operated without CPB. The groups were matched for gender, age, ejection fraction and preoperative risk factors. The incidence of postoperative complications was lower in patients operated without CPB (5.77% vs. 21.15%). The mortality rate was reduced in patients operated without CPB (0.00% vs. 5.76%). There were reduced need for transfusion in patients operated without CPB (0.28 vs. 1.11 units of blood). The average time spent on respirators was shorter in patients operated without CPB (1.50 vs. 4.76 hours). The average time of total hospitalisation was also shorter in patients operated withouth CPB (6.53 vs. 8.13 days). In conclusion CABG without CPB has many advantages compared to the conventional method. Mortality and morbidity are reduced and there is less need for transfusion. The time spent on mechanical ventilation is reduced and less time is spent in intensive care and the total hospitalisation time is also less.

Transit time flow measurements in coronary surgery: the experience from a new center in Bosnia.

BACKGROUND: A new cardiovascular center in Tuzla, Bosnia Herzegovina was opened for cardiac procedures in September 1998. In the first three years of operation, a total of 440 coronary artery bypass grafting (CABG) procedures were performed there. Off-pump coronary artery bypass (OPCAB) was emphasized as the main tool for surgical revascularization. Transit time flow measurement (TTFM) was used routinely to check graft patency. The purpose of this paper is to report on flowmetry results in the Tuzla CABG population. METHODS: All patients were considered candidates for both on-pump (ONCAB) and off-pump (OPCAB) CABG procedures. Approximately 60% of the procedures were performed as ONCAB and the rest as OPCAB. For all patients, TTFM was performed on all grafts. RESULTS: Eighteen patients were converted from OPCAB to ONCAB. Revision was required for 1.8% of the grafts. All grafts were successfully revised and were patent at the time of wound closure. CONCLUSION: We believe that TTFM is a crucial tool in CABG. It offers a reliable and inexpensive tool for quality assurance in coronary revascularization.