[Myocardial revascularization in chronic coronary artery disease. State of art].

The review addresses debatable issues of myocardial revascularization in chronic forms of ischemic heart disease, shows major differences between percutaneous coronary intervention and coronary artery bypass grafting in terms of long-term prognosis, and the dependence of the results on the clinical profile of the disease. The review of current publications demonstrates advantages of open surgery in long-term survival and prevention of adverse outcomes in target groups of patients.

[The Case of Successful Surgical Treatment of a Patient With Thoracic Endograft Infection in 5 Years After Thoracic Endovascular Aortic Repair].

We present here a case of successful staged treatment of a patient with para-aortic abscess that arose 5 years after thoracic endovascular aortic repair because of thoracic aortic aneurysm. After stabilization of the patient's condition by intensive antibiotic therapy we performed left-subclavian extra-thoracic debranching as the first stage of the surgical treatment. In 2 weeks via median sternotomy and on-pump we removed the infected endograft and performed extraanatomical ascending-to-descending aortic bypass with good postoperative result.

Estudo multicêntrico comparativo de quatro diferentes tipos de sensores: atividade, acelerômetro, temperatura e período de pré-ejeçäo / Comparative study with different rate adaptive pacing systems

Recentemente diferentes princípios têm sido utilizado para estimular o coraçäo na tentativa de recuperar o débito cardíaco. Neste estudo multicêntrico, foram comparadas as respostas à estimulaçäo por 4 tipos de sensores, sendo 3 tipos de resposta de alça aberta (atividade física, acelerômetro e temperatura venosa central) implantados em 30 (SSIR-8 e DDDR-22), 9(SSIR-5 e DDDR-4) e 12 (SSIR) pacientes respectivamente. Um outro sensor do tipo alça fechada, sensível às variaçöes do sitema nervoso autôno, foi implantado em 57 pacientes, todos no modo DDDR. Os resultados obtidos durante a realizaçäo de atividade física diária, de teste ergométrico e de Holter de 24 horas foram comparados sendo possível observar uma maior fidelidade na curva de resposta de frequência frente a atividade física, nos pacientes submetidos à estimulaçäo de alça fechada

Sensing lead insulation fractures following implantable cardioverter-defibrillator placement.

The insulation of implantable cardioverter-defibrillator (ICD) sensing leads can fracture, causing device malfunction. Before March 1989, 32 patients received silicon CPI K54 sensing leads. Of these, four (12.5%) experienced discharges while in sinus rhythm. Subsequent ICD interrogation revealed that abdominal muscular contraction triggered discharges in two patients, but no abnormal sensing could be elicited in the other two patients. These patients subsequently were found to have sensing lead fractures. All sensing leads appeared intact radiographically but at reoperation were found to have insulation fractures 2-4 cm from the pin. The mechanism of fracture appears to be related to chronic intermittent lead compression between the anterior abdominal wall musculature and the ICD generator. Since March 1989, 134 patients have undergone ICD implantation with improved CPI 4312 sensing leads; none of these patients has experienced sensing lead fractures. The insulation of these leads is 2.5 times thicker than the K54 (1.0 mm vs. 0.4 mm). Patients with K54 sensing leads are at an increased risk for sensing lead insulation fracture and merit close surveillance. More importantly, sensing lead fractures must be considered in patients who present with inappropriate ICD discharges.

Prophylactic implantable defibrillator patches in patients at high risk for malignant ventricular dysrhythmias.

The indications for prophylactically placing implantable cardioverter defibrillator (ICD) patches at cardiac surgery are unclear. Over the past 4 years, 25 patients have undergone placement of prophylactic ICD patches at the authors' institution. Indications were severe coronary artery disease with ventricular tachycardia (VT) (n = 14) or ventricular fibrillation (VF) (n = 2), and left ventricular aneurysmectomy and/or subendocardial resection (SER) (n = 9). Four patients died in-hospital, three from refractory VT (which could be transthoracically cardioverted until recurrence was unremitting), and one from congestive heart failure (CHF). All of the remaining 21 patients underwent post-operative electrophysiologic studies (EPS), and 12 had inducible VT (8/14 CABG, 4/7 SER). Eight of the 12 inducible patients had generators implanted, whereas 3 patients were controlled medically. One patient refused generator implantation and died at home from sudden cardiac death, and one initially non-inducible patient required late ICD generator placement, yielding a total of nine patients who received generators. All nine of these patients are currently alive at 14 +/- 7 months follow-up, and five have subsequently received appropriate ICD discharges. In patients undergoing cardiac surgery considered preoperatively or intraoperatively to be at increased risk for VT/VF and too unstable for preoperative EPS, prophylactic ICD patches should be considered.

Surgical treatment of symptomatic, drug-resistant ventricular bigeminy and other forms of complex ventricular ectopy (ventricular allorhythmias).

This article describes 18 patients with drug-resistant ventricular bigeminy and other forms of complex ventricular ectopy (allorhythmias) associated with recurrent syncope. Particular emphasis is placed on the electrophysiologic methods used to characterize the basis of these arrhythmias and to accomplish isochronous mapping to identify their site of origin. A malignant course of drug-resistant bigeminy in combination with other rhythm disorders was accepted as indications for surgical intervention. Cryosurgery was the method used most frequently for the ablation of arrhythmogenic myocardium. All 18 patients underwent postoperative electrophysiologic studies and Holter monitoring to determine the efficacy of the operation. Fifteen of the 18 patients were cured of their symptomatic arrhythmia. Thus surgical intervention is an effective method for the treatment of patients with symptomatic, drug-resistant ventricular allorhythmias.

Anatomical variants of sinoatrial and atrioventricular node arteries.

The authors investigated on 70 hearts taken from deceased subjects of either sex, aged 19 to 75 years, anatomical variants of sinoatrial (SAN) and atrioventricular node (AVN) arteries. As regards the branching of the SAN artery from the right and left coronary artery (RCA, LCA), they found altogether 14 variants of connection with the anterior atrial sulcus and the orifice of the superior vena cava. As regards the branching of the AVN from the RCA and the LCA, they identified altogether 6 variants of connection with the venous sinus orifice and the base of the interventricular septum. Problems of surgical interventions on SAN and AVN arteries and mechanisms of possible traumatization in the course of these operations are discussed. Surgical lesions can be prevented by thorough analysis of coronarograms and by taking into account anatomical variants of SAN and AVN arteries.