A Patient with SIADH, Urinary Retention, Constipation, and Bell's Palsy following a Tick Bite.

Introduction. Lyme disease is the most common vector borne disease in the USA caused by the bacterium Borrelia burgdorferi. If untreated, Lyme disease can cause a variety of secondary symptoms often difficult to interpret. Some of the rare manifestations of Lyme disease include SIADH-like syndrome, enteroparesis, and urinary retention. Case Report. A 69-year-old male presented with anorexia and constipation and was found to have hyponatremia. Several days after admission, Bell's palsy developed and he experienced urinary retention requiring catheterization. Lyme disease was confirmed on serology, and he recalled a rash on his elbow four weeks prior. Ceftriaxone was started and the patient improved; he had multiple bowel movements after receiving laxatives and the Foley catheter was removed; serum sodium normalized with fluid restriction. He was discharged home and was well with symptoms completely resolved at three-month follow-up. Discussion. There should be a high alert of atypical presentation of this common tick bite associated infection. Review of the literature revealed ten similar cases, but only three of these patients were reported to have a combination of SIADH, urinary retention, and enteroparesis.

Connective tissue changes in a mouse model of vein graft disease.

AIM: The extracellular matrix plays an important physiological role in the architecture of the vascular wall. In arterialized vein grafts severe early changes, such as thrombosis and neointimal hyperplasia occur. Paclitaxel is in clinical use as antiproliferative coating of coronary stents. We aimed to investigate the early connective tissue changes in arterialized vein grafts and the influence of perivascular paclitaxel treatment in an in vivo model. METHODS: C57 black mice underwent interposition of the vena cava into the carotid artery. Neointimal hyperplasia, thrombosis, acid mucopolysaccharides (Alcian), collagen fibers (trichrome Masson), elastic fibers, and apoptosis rate (TUNEL) were quantified in paclitaxel treated veins and controls. RESULTS: In both, controls and paclitaxel treated vein grafts acid mucopolysaccharides and elastic fibers were found predominantly in the neointima, whereas collagen fibers were found mainly in the media and adventitia. At 4 weeks postoperatively the neointimal thickness in controls was 52 (13-130) microm, whereas in 0.6 mg/mL l paclitaxel treated veins it was 103 (43-318) microm (P=0.094). At 8 weeks postoperatively paclitaxel treated veins showed a significantly increased neointimal thickness of 136 (87-199) microm compared with 79 (62-146) microm in controls (P=0.032). There was no difference in apoptosis rate between the two groups (P=NS). Even with the lowest concentration of 0.008 mg/mL paclitaxel veins showed a neointimal thickness of 67 (46-205) microm at 4 weeks postoperatively (P=NS vs controls). CONCLUSION: Early vein graft disease is characterised by an accumulation of acid mucopolysaccharides and elastic fibers in the thickened neointima. Paclitaxel treatment increases the neointimal hyperplasia in mouse vein grafts in vivo.

Primary ovarian carcinoid heart disease curatively treated with a two-stage procedure.

Primary ovarian carcinoid disease with cardiac involvement is a very rare syndrome, which requires interdisciplinary management. We report on a patient with primary ovarian carcinoid tumor with severe tricuspid valve insufficiency who was curatively treated after successful tumor resection and tricuspid valve replacement.

Do manual assisting maneuvers increase speed and technical performance in robotically sutured coronary bypass graft anastomoses?

BACKGROUND: Robotic endoscopic coronary artery bypass grafting procedures usually are performed as solo surgery operations. This study aimed to investigate whether manual assistance can reduce suturing times and anastomotic suturing problems in robotic coronary artery surgery. METHODS: In isolated pig hearts, the right coronary artery was excised from the epicardium as a pedicle. This pedicled vessel, which resembles the internal mammary artery, was sutured to the left anterior descending artery using the daVinci telemanipulation system. The anastomosis was performed in a running fashion using 7/0 Pronova. In group 1 (n = 20), the suture was performed by the console surgeon as a solo operation. In group 2 (n = 20), the anastomosis was assisted by a team member using an endo forceps. The operations were performed by five surgeons of different training levels. RESULTS: The overall anastomotic time was 24 +/- 15 min in group 1 and 22 +/- 12 min in group 2. The difference was not significant. The rate for anastomotic suturing problems (thread rupture, knot formation, sling formation, needle bending) was 8 in 20 (40%) in group 1 and 8 in 20 (40%) in group 2 (no difference). Anastomotic times and anastomotic suturing errors were dependent on surgeon experience. All anastomoses in both groups showed correct suture alignment and were probe patent. CONCLUSION: In a wet lab model of robotic coronary anastomoses, assisting maneuvers do not decrease suturing speed. Similar suturing quality can be achieved whether the suture is performed in a solo fashion or in an assisted manner.

Placement of endovascular stent-grafts for emergency repair of acute traumatic aortic rupture: a single-centre experience.

The aim of this retrospective study was to evaluate mid- and long-term results of endovascular stent-graft placement for emergency repair of acute traumatic thoracic aortic rupture. From 1996 through 2005, 22 consecutive patients (mean age: 38.7 years) underwent endovascular repair of acute traumatic thoracic aortic rupture located at the aortic isthmus in most cases. All patients were at high surgical risk due to severe associated injuries. The endografts were inserted via femoral or iliac artery access under fluoroscopic guidance. Follow-up was performed postinterventionally, at 6 and 12 months and yearly thereafter, and included clinical examination and computed tomography (CT) scans. Technical and clinical success rates were 86.3%. Mean follow-up was 31.7 months. Three patients developed early type I endoleak due to the inability of the rigid graft to adapt to the curved aortic contour. In two of them conversion to open surgery was necessary. One patient had late type I endoleak and died. No other complications were observed. The outcome was successful in most patients. The mid- and long-term results of our current study are promising. However, early type I endoleak represents a problem, especially in adolescent patients with a marked curvature of the aortic arch.

Technical challenges in totally endoscopic robotic coronary artery bypass grafting.

OBJECTIVE: Robotic technology is a prerequisite for performance of totally endoscopic coronary artery bypass grafting. During the implementation phase of totally endoscopic coronary artery bypass, surgeon-related technical difficulties might be encountered. It was the aim of this study to assess the incidence of these challenges, to find risk factors, and to describe clinical results associated with technical errors. METHODS: From October 2001 through October 2004, 40 patients received robotically assisted totally endoscopic left internal thoracic artery grafts to the left anterior descending coronary artery system with the da Vinci telemanipulation device. All patients underwent remote access cardiopulmonary bypass perfusion through groin access, and all anastomoses were performed on the arrested heart. RESULTS: Undesirable technical events of various grades occurred in 20 (50%) of 40 patients: bleeding from a port hole in 3 (8%), left internal thoracic artery damage in 3 (8%), epicardial lesion in 3 (8%), remote access perfusion problems in 9 (23%), bleeding from the anastomosis in 4 (10%), and anastomotic stenosis in 2 (5%). There was no hospital mortality. The following differences were noted between patients without technical difficulties (group 1) and those in whom problems occurred (group 2): total operative time of 314 minutes (260-540 minutes) versus 418 minutes (270-690 minutes; P = .007), ventilation time of 6 hours (0-26 hours) versus 14 hours (0-278 hours; P = .004), intensive care unit stay of 20 hours (11-70 hours) versus 44 hours (16-336 hours; P=.183), hospital stay of 7 days (4-13 days) versus 8 days (5-21 days; P = .038), and cumulative freedom from angina at 36 months of 93% versus 100% (P = .317). CONCLUSION: We conclude that technical difficulties during totally endoscopic coronary artery bypass grafting translate into markedly increased operative time, moderately prolonged postoperative ventilation time, and slightly increased hospital stay. Short-term survival and freedom from angina, however, do not seem to be compromised.

Factors associated with mortality and long time survival in patients undergoing modified Bentall operations.

AIM: We report our results on mortality, morbidity and long time events after composite graft replacement of the aortic root and ascending aorta/aortic arch and factors associated with them. METHODS: Seventy-four patients, aged 52 years (15-73) underwent modified ''button'' Bentall operation. The indication for operation was acute dissection in 29 (39%) patients, chronic dissection in 3 (4%), aortic regurgitation after previous replacement of the ascending aorta because of aortic dissection in 2 (3%) and non dissecting aneurysm in 40 (54%). Concommitant procedures were (partial) replacement of the aortic arch in 11 (15%) and coronary artery bypass grafting in 5 (7%). Six patients (8%) had undergone previous cardiac surgery. Mean follow up was for 49 +/- 46 months (maximum 198). RESULTS: Length of intensive care unit (ICU) stay was 3 days (1-72). Hospital mortality was 12%. Factors significantly associated with hospital mortality were: aortic dissection, cardiopulmonary bypass time, aortic cross clamp time, deep hypothermic circulatory arrest, low cardiac output syndrome, revision due to bleeding, renal failure requiring hemofiltration, multisystemic organ failure and sepsis. None of these factors was significantly associated with long term survival. Survival rates including hospital deaths were 86%, 84%, 75% and 75% after 1, 3, 5 and 7 years respectively. Pseudoaneurysm at the composite graft occurred in 3%, infection of the prosthesis in 1%. Neither valve thrombosis nor thromboembolic events occurred postoperatively. CONCLUSIONS: Modified Bentall operation is a demanding operation with acceptable hospital mortality. The long time survival rates are good and the big majority of patients is eventfree after operation.

Treatment of double vessel coronary artery disease by totally endoscopic bypass surgery and drug-eluting stent placement in one simultaneous hybrid session.

Hybrid coronary artery revascularization is a combination of minimally invasive coronary artery surgery and catheter-based coronary intervention. Hybrid procedures enable adequate revascularization of patients with multivessel coronary artery disease without complete opening of the chest and with the advantage of the most durable option, a left internal mammary artery (LIMA) graft is placed to the left anterior descending (LAD) artery. The hybrid concept is gaining renewed interest because totally endoscopic LIMA to LAD placement has become feasible and because drug-eluting stents in non-LAD targets may be competitive even for arterial bypass grafts. Simultaneous hybrid procedures would be desirable. We report on a case in which robotic totally endoscopic LIMA to LAD grafting using the da Vinci telemanipulation system was combined with placement of a rapamycin coated stent to the right coronary artery in one single procedure.

Ongoing procedure development in robotically assisted totally endoscopic coronary artery bypass grafting (TECAB).

BACKGROUND: Totally endoscopic coronary artery bypass grafting (TECAB) using robotics requires stepwise introduction into a heart surgery program. It is the aim of this study to evaluate the state of procedure development after continued application of telemanipulation techniques in the clinical setting. We also sought to assess perioperative and intermediate term clinical results after robotically assisted CABG. PATIENTS AND METHODS: From June 2001 to March 2005, robotically assisted CABG using the daVinci system was carried out in 107 patients with single and multi-vessel coronary artery disease. The following procedures were performed: robotically assisted endoscopic left internal mammary artery (LIMA) harvesting and completion of the procedure as conventional CABG, MIDCAB, or OPCAB (n = 22), robotically assisted suturing of LIMA-to-LAD anastomoses during conventional CABG (n = 28), TECAB on the arrested heart using remote access perfusion (n = 48), TECAB on the beating heart using an endostabilizer (n = 8), takedown of adhesions (TECAB intended) (n = 1). RESULTS: Hospital mortality was 0% and cumulative risk adjusted mortality reached 1.6 lives saved versus EuroSCORE predictions. Undesirable surgical events (USE) such as conversion, on table revision, or postoperative revision procedures occurred in 34 out of 107 (32%) patients. Median ventilation time and ICU stay, however, were 11(0-278) hours and 21(11-389) hours, respectively. Cumulative 3 years survival was 100% and freedom from angina at 3 years was 97%. CONCLUSIONS: We conclude that despite being surgically challenging robotically assisted coronary artery surgery can be implemented with acceptable safety. TECAB procedures have reached a reproducible state. Perioperative mortality after robotically assisted CABG may be lower than predicted. Intermediate term clinical results are very satisfactory.

A variation of the radial artery and its clinical implications for coronary artery bypass grafting.

Since the radial artery is increasingly harvested as a bypass graft, surgeons are confronted with its anatomical variations. We report on a radial artery running laterally around the distal part of the radius, while a superficial palmar branch is running straight down. The radial artery can be dissected distally to get enough length for the bypass graft, but attention has to be paid to the superficial branch of the radial nerve running nearby to prevent postoperative paresthesias and numbness. The superficial palmar branch of the radial artery can be ligated. Allen's test in such a case is not valid because it is always negative.

Is the axillary artery a suitable cannulation site in aortic surgery?

AIM: The axillary artery is currently gaining interest as an alternative to femoral artery cannulation in aortic surgery. It was the aim of our study to evaluate the feasibility, safety, and efficacy of axillary artery cannulation in a series of patients undergoing surgery of the ascending aorta and/or the aortic arch. METHODS: From 1998 to 2002 cardiopulmonary bypass (CPB) perfusion via the axillary artery was intended in 35 patients (28 male), median age 61 (22-77) years. The underlying disease was acute aortic dissection type A in 22/35 (63%), chronic aortic dissection type A in 2/35 (6%), ascending aortic aneurysm in 8/35 (22%), aortic regurgitation after previous ascending aortic replacement in 1/35 (3%), pseudoaneurysm after Bentall operation in 1/35 (3%) and coronary artery disease with severe arteriosclerosis of the aorta in 1/35 (3%). RESULTS: Conversion to femoral artery or ascending aortic cannulation was necessary in 3 patients. In the other cases, adequate CPB flows of 2.4 l/m2/min were achieved. In 1 case local dissection of the axillary artery occurred after emergency cannulation. No postoperative complications related to axillary artery cannulation, such as upper extremity ischemia, brachial plexus injury, or local wound infection occurred. No new postoperative stroke was noted, hospital mortality was 4/35 (11%) patients. CONCLUSION: Axillary artery cannulation is feasible in the majority of cases and seems to be a safe and effective method in surgery of the ascending aorta and aortic arch. Several disadvantages of femoral artery cannulation and perfusion can be avoided.

Robotic totally endoscopic coronary artery bypass: program development and learning curve issues.

BACKGROUND: The introduction of new procedures in heart surgery is a critical phase that includes learning curves and the risk of increased mortality or morbidity. Totally endoscopic coronary artery bypass grafting using robotic techniques represents such an innovative procedure. The aim of this report is to demonstrate the safe introduction of totally endoscopic coronary artery bypass grafting using a stepwise and modular approach. METHODS: From June 2001 until December 2002, 50 procedures were performed using the da Vinci telemanipulator system. After baseline training the following procedure modules were carried out in a stepwise manner: robotically assisted endoscopic left internal thoracic artery harvesting and completion of the procedure as conventional coronary artery bypass grafting, minimally invasive direct coronary artery bypass, or off-pump coronary artery bypass (n = 19), robotically assisted suturing of left internal thoracic artery to left anterior descending anastomoses during conventional coronary artery bypass grafting (n = 15), totally endoscopic coronary artery bypass grafting on the arrested heart using remote access perfusion and aortic endocclusion coronary bypass grafting (n = 15). One patient was excluded intraoperatively from a robotic procedure due to pleural adhesions. RESULTS: A significant learning curve was observed for left internal thoracic artery takedown time, y(min) = 181 - 39 x ln(x) (x = procedure number) (P <.001), and total operative time in totally endoscopic coronary artery bypass grafting, y(min) = 595 - 87 x ln(x) x = (procedure number) (P =.028). The conversion rate in totally endoscopic coronary artery bypass grafting was 2/15. Intensive care unit stay correlated significantly with total operative time (r =.427, P =.002). There was no hospital mortality. CONCLUSION: Totally endoscopic coronary artery bypass grafting can be safely implemented into a heart surgery program. Learning curves are steep for robotic left internal thoracic artery takedown and for performance of totally endoscopic coronary artery bypass grafting. Long operative times translate into prolonged intensive care unit stay in specific cases but not into increased mortality.

The axillocoronary bypass. Blood flow and short-term graft histology in a porcine model.

BACKGROUND: Bypass grafts arising from the axillary artery may be indicated for complications during minimally invasive direct coronary artery bypass grafting, for redo operations and for management of a severely atherosclerotic ascending aorta. As basic data research on this technique is scanty, we investigated intraoperative function and postoperative morphology of axillocoronary bypass grafts in a porcine model. METHODS: Thirteen German domestic pigs received an axillocoronary vein graft (Group I, n=7) or an aortocoronary vein graft (Group II, n=6) to the left anterior descending artery. In Group I the proximal anastomosis was performed to the left axillary artery, and after partial rib resection the graft was brought transpleurally to the target vessel. In both groups the coronary anastomosis was carried out on the beating heart without cardiopulmonary bypass. Graft flow was measured using transit time ultrasonic flow probes. RESULTS: Intraoperatively all grafts showed a typical diastolic flow profile. Stable graft flow was lower in axillocoronary bypass grafts: 47 (30-60 mL/min) in Group I and 65 (35-126 mL/min) in Group II (p=0.005). Flow given as percentage of cardiac output, however, did not differ between the two grafts: 0.9 (0.6-1.2%) in Group I and 1.2 (0.8-2.4%) in Group II (p=NS). At day 4 after surgery there was no clear histologic predilection site for microtrauma and early degenerative changes in the axillocoronary graft. CONCLUSIONS: Axillocoronary bypass flow compares well with flow in the aortocoronary graft. Microtrauma after implantation and early degenerative changes in the axillocoronary vein bypass are not particularly impacted by the thoracic entry site.

Off pump coronary artery bypass grafting in EuroSCORE high and low risk patients.

OBJECTIVE: Off pump coronary artery bypass grafting (OPCAB) is claimed to reduce the operative morbidity and mortality in high risk patients. It was the aim of the study to compare the outcome of OPCAB patients classified as high- and low risk according to the EuroSCORE. METHODS: Medical records of patients undergoing off pump coronary artery bypass grafting (n=126) at our institution between 1998 and 2001 were retrospectively reviewed. We classified them into two subgroups: low risk (EuroSCORE < or = 5, n=72, male 58 (81%), female 14 (19%), age 61 (37-78) years) and high risk (EuroSCORE >5, n=54, male 32 (59%), female 22 (41%), age 73 (42-83) years). RESULTS: EuroSCORE high risk patients showed significantly higher rates of blood transfusion (70 vs 31%; P<0.0001), intraaortic balloon pump insertion (16 vs 3%; P=0.013), atrial fibrillation (43 vs 22%; P=0.014), and renal failure (13 vs 3%; P=0.028). ICU length of stay was significantly longer in the high risk group (25 vs 22 h; P=0.002). There was also a higher perioperative mortality in the high risk group (9 vs 0%; P=0.008). CONCLUSION: From these data we conclude that using off pump coronary artery bypass grafting results as predicted by the EuroSCORE can be achieved. OPCAB is safe for low risk patients. Major complications seem to occur preferentially in the high risk group.

Epiaortic ultrasound and intraoperative transesophageal ecocardiography for the thoracic aorta atherosclerosis assessment in patient undergoing CABG. Surgical technique modification to avoid cerebral stroke.

BACKGROUND: Cerebral complication during coronary artery bypass surgery (CABG), still occurs in spite of cardiopulmonary bypass (CPB) technology advances. Our study sought to assess the role of epiaortic ultrasound (EAS) and intraoperative transesophagial ecocardiography (TEE) in detection of patients with atherosclerosis of the thoracic aorta and high risk for cerebral embolisation. Consequently our surgical strategies modification for a better cerebral protection. METHODS: Our lot study comprise 352 patients undergoing EAS and TEE, during CABG. EAS was performed before opening of the pericardium using a 7.5 MHz ultrasonic probe packed in a sterile bag. In the presence of moderate aortic atherosclerosis (maximum aortic wall thickness of 3 mm) primarily single aortic cross-clamping and choose of aortic cannulation place was carried out. In cases of severe aortic atheroma (maximum aortic wall thickness > 5 mm or mobile plaque), aortic no touch technique, off-pump were used. From 34 patients with severe ascending aortic atherosclerosis 22 of these patients (18 male, 4 female, age 72(57-79), Parsonet Score 11(0-8), Euroscore 8(2-13), McSPI Stroke Risk Index 6 (1-30%) were managed on "no touch technique", Off-pump. All patients received at least one left internal mammary artery (LIMA) in situ graft and additional extraanatomical bypass conduits: venous Y-graft from IMA (n = 14), arterial Y-graft from LIMA (n = 3), vein graft from axillary artery (n = 3), vein graft from the RIMA stump (n = 3). Median operative time was 240 (115-435) min. RESULTS: We found a mild aortic atherosclerosis in 151 patients (43%), moderate in 167 (47%) and severe in 34 patients (8.8%).. Operative mortality was 2/22 in a group with high risk index, from another cause than cerebral stroke. No cerebral stroke occurred. The rate of perioperative myocardial infarction (CKMB > 50U/l) was 5/22. Median stay in ICU, 54 hours (15-1245 hours). After a median follow up period of 8 months one death occurred from cerebral stroke and no myocardial infarction. CONCLUSION: Accurate detection of atheroma on ascending aorta and aortic arch by a combination between EAS and TEE and in special surgical technique modification using off-pump revascularization and extraanatomical bypass for the management of a heavily calcified aorta can result in a very low stroke rate despite a considerable stroke risk. The hospital mortality and morbidity can be lower than predicted by Euroscore and Parsonet Score.

Extraanatomical coronary artery bypass grafts on the beating heart for management of the severely atherosclerotic ascending aorta.

BACKGROUND: Crossclamping a severely atherosclerotic ascending aorta carries a significant risk of stroke in coronary artery bypass grafting. Besides other techniques aortic no touch concepts are increasingly applied for management of this problem. METHODS: Out of 407 patients undergoing epiaortic scanning during coronary artery bypass grafting 38 (9.3%) exhibited severe ascending aortic atherosclerosis. 22 of these patients (18 male, 4 female, age 72 (57-79) years, Parsonnet Score 11 (0-18), Euro Score 8 (2-13), McSPI Stroke Risk Index 6 (1-30) %) were operated on using a beating heart and aortic no touch technique. All patients received at least one internal mammary artery (IMA) in situ graft and additional extraanatomical bypass conduits: venous Y-graft from the IMA (n=14), arterial Y-graft from the IMA (n=3), vein graft from the axillary artery (n=3), vein graft from the IMA stump (n=2), vein graft from the innominate artery (n=2). RESULTS: No stroke occurred. The rate of perioperative myocardial infarction (CKMB rt; 50 U/l) was 5/22. Median ICU length of stay was 54 (15-1245) h. Hospital mortality was 2/22. Pre- and postoperative angina class (CCSC) were 3.3 +/- 0.9 and 1.4 +/- 0.9 respectively (p<0.001). After a median follow up period of 8 months 3 deaths, one stroke, and one myocardial infarction occurred. On 3D multislice CT scan reconstructions which were performed in 13 patients during the first postoperative year all IMA grafts to the LAD and 11 out of 13 extraanatomical vein grafts were shown to be patent. CONCLUSION: Performance of beating heart extraanatomical coronary artery bypass grafts for management of a heavily diseased ascending aorta can result in a very low stroke rate despite a considerable stroke risk. The complexity of the procedures may be reflected by a relatively high rate of perioperative myocardial infarctions. Perioperative mortality as well as short term patency of extraanatomical bypass grafts seem to be acceptable.

Analysing ventricular fibrillation ECG-signals and predicting defibrillation success during cardiopulmonary resuscitation employing N(alpha)-histograms.

Mean fibrillation frequency may predict defibrillation success during cardiopulmonary resuscitation (CPR). N(alpha)-histogram analysis should be investigated as an alternative. After 4 min of cardiac arrest, and 3 versus 8 min of CPR, 25 pigs received either vasopressin or epinephrine (0.4, 0.4, and 0.8 U/kg vasopressin versus 45, 45, and 200 microg/kg epinephrine) every 5 min with defibrillation at 22 min. Before defibrillation, the N(alpha)-parameter histogramstart/histogramwidth and the mean fibrillation frequency in resuscitated versus non-resuscitated pigs were 2.9+/-0.4 versus 1.7+/-0.5 (P=0.0000005); and 9.5+/-1.7 versus 6.9+/-0.7 (P=0.0003). During the last minute prior to defibrillation, histogramstart/histogramwidth of > or =2.3 versus mean fibrillation frequency > or =8 Hz predicted successful defibrillation with subsequent return of a spontaneous circulation for more than 60 min with sensitivity, specificity, positive predictive value and negative predictive value of 94 versus 82%, 96 versus 89%, 98 versus 93% and 90 versus 74%, respectively. We conclude, that N(alpha)-analysis was superior to mean fibrillation frequency analysis during CPR in predicting defibrillation success, and distinction between vasopressin versus epinephrine effects.

[Variability of coping strategies in coronary artery bypass surgery patients]. / Zur Variabilität des Coping bei Patienten mit aortokoronarer Bypass-Operation.

The state-versus-trait discussion in coping research would become more meaningful if attention is paid to the variability both of coping patterns in individual patients as well as stability of single coping strategies over time. 35 patients undergoing coronary artery bypass surgery were interviewed three times about their coping and stress experience: after cardiac catheterization, on the day before surgery, and six days after surgery. Anxiety and depression were measured. A coping attitude of "positive passivity" was present at all three points of time. While the group means were stable, vast interindividual differences occurred. Also, there was a high degree of scatter in the stability of single coping items; emotion related coping modes were more stable than cognition and action related ones. The variability of the patients' coping patterns correlated positively with the amount of stress experienced and with preoperative depression. Different coping strategies are linked to a different degree with personality traits, emotional coping modes revealing the closest connection. The variability of individual coping efforts might be linked to a personality disposition characterized by a vulnerability for stress and depressive reactions.

Minimally invasive subclavian/axillary artery to coronary artery bypass (SAXCAB): review and classification.

BACKGROUND AND PURPOSE: Subclavian/axillary artery to coronary artery bypass (SAXCAB) surgery is defined as a minimally (or less) invasive coronary revascularization procedure where one or more grafts are anastomosed to the second or third parts of the subclavian artery or any of the three parts of the axillary artery (inflow source) and attached to one or more coronary arteries, and where there are two separate minimally invasive incisions to expose the target coronary artery and the inflow sources, respectively. The indications and contraindications for SAXCAB surgery are discussed, and the relevant chest wall anatomy and that of the subclavian and axillary arteries are reviewed. The effect of respiration and anatomic variability as they impact the SAXCAB graft are discussed. Three components of the anatomy that are important in SAXCAB surgery are discussed: The relation of the first rib to the clavicle insofar as it affects access to the third part of the subclavian artery, the anatomy of the subclavian and axillary arteries and their branches, and the anatomy of the chest wall and its movement. In addition, the different SAXCAB variations that have been applied clinically are reviewed and classified, and future aspects of SAXCAB research are discussed. SAXCAB surgery is unique among the different types of minimally invasive direct coronary artery bypass (MIDCAB) surgery because of the enormous diversity of the techniques that have been described. Based on these descriptions, a new classification of SAXCAB grafting is proposed depending on whether the graft is inside or outside the rib cage and whether or not the coronary artery is exposed by rib resection or through an intercostal space. The third part of the classification takes into consideration the mode of entry into the chest, whether it is by rib resection or through an intercostal space. METHODS: Inquiries were made by telephone and by mail in the year 2000 to a number of surgeons who had published details of their SAXCAB techniques, and informal information was obtained by a series of personal communications as to the estimated number of operations they had performed and the outcomes. Published data was also used to formulate a rough guide as to the international status of the procedure at this time. RESULTS: The total estimated international experience is about 100 cases and the patency is between 70 and 100 percent in the time frame of about one to two years. CONCLUSIONS: The MIDCAB technique in general has been successful in providing an alternative way to revascularize the coronary arteries, and the SAXCAB has proved to be one of the most interesting classes of MIDCAB surgery. SAXCAB grafts seem to be unique among coronary revascularization procedures and, indeed, probably almost all vascular procedures, in that there is enormous diversity in the route for the graft from the inflow source to the target coronary artery. Being knowledgeable about the different varieties of SAXCAB surgeries will help the surgeon during a rescue operation as the surgery can be tailored to suit a particular patient. The SAXCAB seems to be a very safe operation, and it is striking that so far no one has reported any major complications.

Hypoxia induces heat shock protein expression in human coronary artery bypass grafts.

OBJECTIVE: Heat shock proteins (HSPs) are molecular chaperones which are essential for cell survival. Heat shock and hypoxia markedly increase the expression of several HSPs in various tissues, i.e. heart. In our in vitro study, we investigated whether HSPs are inducible in human vessels which are used as coronary artery bypass grafts. METHODS: We used remnants of the saphenous vein and the internal mammary artery from 34 patients undergoing coronary artery bypass surgery. Each vessel was divided into segments, one for control conditions at 37 degrees C (5% CO(2)-95% air), the remaining ones for thermal (30 min at 42 degrees C) or hypoxic treatment (6 h oxygen deprivation with nitrogen). The expression of Hsp60, Hsp72 and Hsp73 was investigated by immunohistochemistry and Western-blot analysis. RESULTS: Compared to controls, segments of the saphenous vein undergoing heat treatment showed significantly increased expression of Hsp72 in the intima (P=0.035) and Hsp73 in the media (P=0.003). In the internal mammary artery, Hsp72 and Hsp73 were expressed in the intima at significantly higher levels (P=0.042 each). A 6 h oxygen deprivation with nitrogen resulted in elevated levels of Hsp60 (media: P=0.048), of Hsp72 (intima: P<0.001 and media: P=0.004) and of Hsp73 (intima: P=0.029) in the saphenous vein. In the internal mammary artery, Hsp73 expression was significantly enhanced (intima: P=0.048 and media: P=0.017). The results were confirmed by Western-blot analysis in representative veins. CONCLUSIONS: These findings demonstrate the common cellular defense mechanism of HSP expression in response to stress in coronary artery bypass grafts. Hypoxia and heat treatment strongly induce Hsp72 and Hsp73 expression in human coronary artery bypass grafts.