Fast track as a routine for open heart surgery.

OBJECTIVE: Evaluation of thoracic epidural analgesia (TEA), normothermic cardiopulmonary bypass (CPB) and normothermic blood cardioplegia as a routine procedure for fast track open heart surgery. METHODS: Consecutive patients (n=250, age 36--81 years, mean 63, M/F, ratio=4) were subjected to the combination of general anaesthesia using ultra-short acting opiates, TEA, normothermic CBP, normothermic whole blood cardioplegia. Operative procedures included coronary artery bypass grafting (CABG), valve replacement, combined CABG and valves, aortic aneurysm and Maze III. LVEF ranged 20--76%. Eighty percent were in Tuman score 0--5 and 20% in score >5. RESULTS: All patients were extubated within 10 min after skin closure. There was one myocardial infarction. Four percent were shortly treated with cathecholamines. Postoperative atrial fibrillation was noticed in 9.6%. Four transient cerebral ischemic events were encountered. No neurological disturbance related to the use of TEA was seen. Seven patients were reoperated because of bleeding. Blood transfusion was given to 6.4% of the patients. Mortality was 0.8%. CONCLUSIONS: The combined methods provides a way for routine immediate postoperative extubation, with low morbidity and short hospital stay.

Effects of the maze operation on health-related quality of life in patients with atrial fibrillation.

BACKGROUND: Maze surgery for atrial fibrillation (AF) is a curative therapy, but its effect on health-related quality of life has not been studied. METHODS AND RESULTS: Maze operations were performed in 48 patients with drug-refractory AF. The majority of patients (80%) had lone AF, and the primary indication for surgery in all patients was AF. The SF-36 Health Survey was used to assess quality of life before operation and at 6 months and 1 year after surgery. Twenty-five patients were available for the 1-year follow-up and completed all questionnaires. Before maze surgery, the SF-36 scores were significantly lower than in the general Swedish population, reflecting significant impairment in well-being, physical and social functioning, and mental health. After maze surgery, the quality of life was significantly improved at 6 months and at 1 year on all scales except for bodily pain, which, however, was not significantly decreased before surgery. At both 6 months and 1 year after maze surgery, quality of life, measured by the SF-36, reached the levels of the general Swedish population. CONCLUSIONS: The maze operation can significantly improve the health-related quality of life in selected groups of patients with both paroxysmal and chronic AF refractory to antiarrhythmic therapy.

Surgical repair of type B aortic dissection complicated by early postoperative lung vein and artery thrombosis.

A 24-year old man with Marfan syndrome previously operated for abdominal aortic aneurysm and type A dissection sustained a type B dissection. He underwent graft replacement of the descending and upper abdominal aorta, complicated by infarction of the left upper lobe and lobectomy was carried out. The postoperative course was uneventful. The mechanism for this rare complication is discussed.

Right internal mammary artery for myocardial revascularization: early results and indications.

The right internal mammary artery (RIMA) was used for coronary artery bypass grafting in 258 patients from October 1985 to October 1991. The RIMA was inserted as the only graft in 8 patients and in combination with the left internal mammary artery (LIMA) in 231 patients, the right gastroepiploic artery in 19, and autologous vein in 184. The patients received a total of 1 to 8 distal anastomoses (mean number, 3.3). A total of 64% of the RIMAs were anastomosed to the left anterior descending coronary artery. The primary indication for use of the RIMA was small-vessel disease in 86 patients, repeat bypass grafting in 32, varicose or stripped saphenous veins in 61, and "selected routine case" in 79. The early (< or = 30 days postoperatively) mortality rate in these four groups was 8.1%, 6.3%, 0%, and 0%, respectively (p < 0.01). Independent risk factors (logistic regression analysis) for early mortality were small-vessel disease, insufficient grafting, repeat coronary artery bypass grafting, diabetes, history of smoking, age of 60 years or older, and family history of ischemic heart disease. Combined into a risk index, these risk factors identified six risk groups with early mortality of 0% in the four low-risk groups and 5.6% and 58.3% in groups V and VI, respectively (p < 0.0001). No RIMA-related variables were risk factors for significant postoperative myocardial enzyme release. Intraoperative electromagnetic flow measurements revealed no differences between the RIMA and LIMA. Early angiographic patency in 50 patients was 98% for the RIMA and 93% for the LIMA.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiarterial coronary artery bypass grafting with special reference to small vessel disease and results in women.

From 1985 to 1991 a total of 220 patients underwent coronary artery bypass grafting (CABG) with at least two native pedicled artery grafts. Bilateral internal mammary artery (IMA) grafting was performed in 201 patients, IMA combined with gastro-epiploic artery (GEA) grafting in five, and double IMA plus GEA grafting in 14; in addition 156 patients received 1-3 vein grafts. The primary indication for elective multi-arterial CABG was coronary arteries of small calibre (small vessel disease) in 77 patients, repeat CABG in 17 (without small vessel disease), varicose/stripped saphenous veins in 57 (without small vessel disease), while the remaining 69 were routine cases; the distribution differed between women (42, 0, 47, and 11%, respectively) and men (33, 10, 19, and 38%, respectively; P < 0.0001). The women also were older (62 +/- 7 vs 56 +/- 9 years; P < 0.001), and had higher prevalences of systemic hypertension, diabetes mellitus, and hypercholesterolaemia. The number of artery grafts and total number of grafts were, however, similar for women and men. Early mortality (< or = 30 days) was 5.6% in women and 2.4% in men (ns). Early mortalities in relation to primary indications were: 7.8% for small vessel disease, 5.9% for repeat CABG, and 0% for both varicose/stripped saphenous veins and routine cases (P < 0.05). Logistic regression analysis identified small vessel disease, insufficient grafting, age of > = 60 years, a history of smoking, a family history of ischaemic heart disease, and female gender as independent risk factors for early mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for chronic left ventricular aneurysm. Benefits and side effects.

Seventy patients who underwent elective resection of symptomatic postinfarction apico-anterior left ventricular (LV) aneurysm with or without coronary revascularization are reviewed. The early (< or = 30 day) mortality was 5.7%. Mural thrombosis occurred in 29 cases (41.4%), unrelated to the degree of preoperative LV impairment and predictable from preoperative LV angiography in only seven cases. The response to surgery comprised significant overall improvement of global LV ejection fraction (LVEF) during rest and of all variables in stress testing. This LVEF recovery correlated significantly with that of peak ejections rate, a variable of myocardial contractility. Contrastingly, right ventricular ejection fraction (RVEF) at rest decreased slightly but significantly without correlation to preoperative RVEF or LVEF. In comparisons between patients with congestive heart failure or angina at rest as dominant symptom, the former group showed greater depression of preoperative watt and LVEF but better postoperative recovery of these variables, while right ventricular deterioration was significant only in the latter. Postoperative recovery was best in patients with poor preoperative LV function (LVEF < or = 20%), even when surgery comprised only aneurysmectomy in isolated but ungraftable LAD disease (5 cases). The observed RV deterioration may be 'nonspecific', but it must be kept in mind as a side effect of the operation, as it detracts unpredictably from postoperative ventricular recovery. Patients with well preserved preoperative LVEF, small LV aneurysm and marginal expected post-aneurysmectomy changes according to LaPlace's law are probably at risk, and surgery should then instead be directed towards preserving the remaining viable myocardium by direct revascularization.

Left ventricular aneurysmectomy in patients with poor left ventricular function.

Physical performance and left ventricular (LV) function in the resting state were assessed in 22 patients with postinfarction anterior-apical left ventricular aneurysm (LVA) and global ejection fraction less than or equal to 20% who subsequently underwent radical LVA resection. The basic findings in the 20 survivors of surgery were significant improvement of global systolic LV function and more or less complete recovery of regional ejection fraction in the predominantly viable low and high lateral LV wall. This improvement was evident in patients with concomitant bypass grafting as well as in those with isolated and ungraftable lesions of the left anterior descending (LAD) coronary artery. We conclude that postinfarction anterior-apical LVA in a poorly functioning LV is suitable for surgical treatment, which can be accomplished with acceptable risk. All graftable stenotic major coronary arteries should be bypassed, in addition to the LVA resection, but a minority of patients with isolated, ungraftable LAD disease are likely to benefit from aneurysmectomy alone.

Revascularization of infarcted vs. viable myocardium. Effects on symptoms, physical performance and global/regional left ventricular function.

Symptoms, physical performance and global vs. regional left ventricular (LV) function were reviewed in 25 patients with postinfarction anterior-apical akinesia and minor dyskinesia who subsequently underwent revascularization of all graftable stenotic vessels. The observed postoperative improvement in functional NYHA capacity and physical performance was not related to significant change in any systolic or diastolic variable of global LV function. 'Nonspecific postoperative septal hypokinesia' developed in most cases. The regional ejection fraction showed slight (nonsignificant) mean increase in the infarcted apex and low anterior wall supplied by the left anterior descending artery, but marked increase in the noninfarcted lateral wall supplied by the left circumflex branch. Hearts with grafted left circumflex artery showed on average lower preoperative and postoperative ejection fraction in the lateral wall than did hearts without such grafting, but the rise in regional ejection fraction was significant only after left circumflex grafting. The clinical response to coronary artery surgery is attributed mainly to functional improvement of non-infarcted myocardium. Revascularization of viable myocardium occurs directly via bypass grafts, but collateral vessels may also contribute.

Revascularization of infarcted myocardium. Effect on myocardial perfusion assessed with quantified Tl-201 SPECT technique.

Myocardial perfusion was studied in 21 patients before and after revascularization of all graftable stenotic vessels following post-infarction anteroapical akinesia and minor dyskinesia. At preoperative and late postoperative evaluation, perfusion abnormalities in identified sectors were quantified with two methods, one (Q1) assessing the extent and the other (Q3) the severity of abnormal perfusion. The preoperative scores with both methods indicated permanent myocardial perfusion defects in all 21 patients and reversible defects, indicating myocardial ischemia, in 16 with Q1 and 14 with Q3. After bypass grafting there was overall reduction of myocardial perfusion defect and of abnormality scores: Notably, 13/21 patients (62%) had decreased permanent myocardial defect score, reflecting reactivation of 'hibernating myocardium'. The findings indicated that obstructed but graftable vessels supplying myocardium with loss of contractile function should be bypassed, since flow contribution to distant, viable myocardium is probable via preserved collateral circulation. This should be particularly relevant for the LAD, because of that artery's septal branches.

Antimicrobial prophylaxis in cardiovascular surgery.

In the past five years three prospective randomized studies compared five different prophylactic antimicrobial regimens in major cardiovascular surgery. In 1980/81 a 4 d cefazolin (CFZ) prophylaxis (16 X 0.5 g) was compared with a 2 d cefuroxime (CFX) administration (4 X 1.5 g). Of the 566 patients who entered the study 281 received CFZ and 285 were given CFX. In 1982/83 a 2 d CFX prophylaxis (4 X 1.5 g) was compared with a two shot ceftriaxone (CRO) prophylaxis (2 g i.v., + 1 g 24 h later). Of the 512 patients enrolled 258 received CFX and 254 CRO. In 1984/85 a 1 d CFZ prophylaxis (4 X 0.5 g) was compared with a single shot prophylaxis of CRO (1 X 2 g). Of the 541 patients who entered the study 272 received CFZ and 269 CRO. All patients of age 16 y or older who were undergoing open heart surgery (n = 1384) and surgery of the major arteries (n = 235) were eligible for trial entry with the following exceptions: patients with preoperative infections, those who had received an antibiotic within 48 h of operation, and any with known allergies to cephalosporins or who had suffered an anaphylactic reaction to any penicillin. The patients were allocated to one of the two treatments by means of a randomized code, stratified for cardiac and major vascular operations. The first dosis was always given prior to surgery at the beginning of anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Perioperative antimicrobial prophylaxis in cardiovascular surgery. A prospective randomized trial comparing two day cefuroxime prophylaxis with four day cefazolin prophylaxis.

In a randomized prospective study, two different regimens of antibiotic prophylaxis have been tested: four-day cefazolin prophylaxis (Kefzol 0.5 gr every 6 h) compared with two-day cefuroxime administration (Zinacef 1.5 gr every 12 h). A total of 569 patients in the two groups were studied in a 10 month period. Haematological, liver function, serum creatinine and urea measurement were made preoperatively and repeated daily for the first four days and after one week. At least five chest X-rays were taken during the hospitalisation. Body temperature was measured regularly every two hours in the ICU and a least twice a day thereafter. The wounds were examined daily and the patients were carefully observed for other infections. Bacteriological examinations of the tips of all inserted catheters and pacemaker wires were undertaken on removal in the first four months of the trial. Swabs of any tracheal or wound secretion or pus taken for bacteriological examinations as also blood cultures in any suspected septicaemia. Of the 569 patients three had to be withdrawn from the study. Of the assessable ones 285 received cefuroxime and 281 were given cefazolin. Seven patients (1.2%) died postoperatively. The total infection rate was 5.5%: 5.7% in the cefazolin group and 5.3% in the cefuroxime group. The overall wound infection rate was 1.8%: 2.5% in the cefazolin group and 1.1% in the cefuroxime group. Septicaemia occurred in 0.5% of the cases. Pneumonia occurred in 11 (1.9%) patients; 1.5% in the cefazolin and 2.5% in the cefuroxime group. Seven patients (1.2%) developed a urinary tract infection; 1.4% in the cefazolin group and 1.1% in the cefuroxime group.(ABSTRACT TRUNCATED AT 250 WORDS)

[A prospective, randomized comparative study between cefazolin and cefuroxime as perioperative antibiotic prevention in cardiovascular surgery]. / Eine prospektive, randomisierte vergleichende Studie zwischen Cefazolin und Cefuroxim als perioperative Antibiotika-Prophylaxe in der Herz- und Gefässchirurgie.

In a randomized prospective study, two different regimens of antibiotic prophylaxis have been tested: 4-day cefazolin prophylaxis (Kefzol, 0.5 g every 6 h) compared with 2-day cefuroxime administration (Zinacef, 1.5 g every 12 h). A total of 569 patients in the two groups were studied over a 10 months' period. Hematological, liver-function, serum creatinine and urea measurements were performed preoperatively and repeated daily for the first four days and after one week. At least five chest X-rays were taken during the hospitalization. Body temperature was measured regularly every two hours in the ICU and at least twice daily thereafter. The wounds were examined daily and the patients were carefully observed for other infections. Bacteriological examinations of the tips of all inserted catheters and pacemaker wires were undertaken on removal in the first four months of the trial. Swabs of any tracheal or wound secretion or pus were taken for bacteriological examinations, and blood cultures were performed for any suspected septicemia. Of the 569 patients, 3 had to be withdrawn from the study. Of the assessable patients, 285 received cefuroxime and 281 were given cefazolin. Seven patients (1.2%) died intra- or postoperatively. The total infection rate was 5.5%; 5.7% in the cefazolin group and 5.3% in the cefuroxime group. The overall wound infection rate was 1.8%; 2.5% in the cefazolin group and 1.1% in the cefuroxime group. Septicemia occurred in 0.5%, pneumonia in 11 patients (1.9%); 1.5% in the cefazolin and 2.5% in the cefuroxime group. Seven patients (1.2%) developed a urinary tract infection; 1.4% on the cefazolin group and 1.1% in the cefuroxime group.(ABSTRACT TRUNCATED AT 250 WORDS)