[Coronary surgery in elderly patients. In-hospital and long-term results]. / Cirugía coronaria en pacientes ancianos. Resultados hospitalarios y a largo plazo.

BACKGROUND: Taking into account the steady increase in the number of elderly patients requiring coronary artery bypass grafting, we sought to analyze the in-hospital and long-term evolution of a group of elderly patients (>/= 75 years) who underwent coronary artery bypass grafting, and to identify clinical predictors of mortality and long-term symptoms. METHODS: Between April 1996 and February 2000, 207 patients older than 75 years of age who had undergone coronary bypass grafting were prospectively and consecutively analyze. Mean age was 78.4 +/- 2.7. RESULTS: An average of 2.6 grafts/patients was constructed. Left mammary artery was used in 93% of patients. The in-hospital incidence of heart failure, atrial fibrillation, preoperative infarction and stroke was 38%, 29%, 4.8% and 2.8% respectively. The in-hospital mortality rate was 5.8%. Mean follow-up was 18 months (25th an 75th percentiles 9-29). Late mortality rate was 4.1% in eight patients. Excluding the in-hospital deaths, the estimated probability of survival (Kaplan-Meier) at 3 years was 94% and the survival freedom from symptoms was 86%. A multivariate analysis showed that only age was predictor of in-hospital mortality (OR 1.16, p = 0.009). Only peripheral vascular disease was found as a predictor of symptoms during the long-term follow-up (p = 0.001). CONCLUSIONS: In this series of senile patients who underwent coronary surgery, those of an older age (> 80 years) showed a higher risk of in-hospital mortality. The presence of peripheral vascular disease is useful in the prognosis assessment of the group.

Myocardial revascularization with radial and mammary arteries: initial and mid-term results.

BACKGROUND: The radial artery is being used with increasing frequency instead of the saphenous vein in coronary artery bypass grafts. We analyzed the in-hospital and midterm results in patients undergoing coronary artery bypass surgery in whom a combination of arterial grafts was used, including radial artery and one or both internal mammary arteries. METHODS: Between 1995 and 1998, 1,023 patients underwent coronary artery bypass surgery using arterial conduits. The left internal mammary artery and the right internal mammary artery were employed in combination with the radial artery. RESULTS: An average of 3.2 grafts per patient were done. The left internal mammary artery and radial artery were used in 100% of patients, the right internal mammary artery in 21.7%, and a venous graft in 31%. The operative mortality rate was 2.5%. On repeat angiography performed in 62 patients before their discharge, the arterial conduits were patent in 98.4%. Mean follow-up was 25.0 +/- 9.6 months (1 to 48 months). The probability of survival was 92.8%. CONCLUSIONS: Revascularization using mammary and radial artery grafts is safe. Complications are not higher than those observed with saphenous vein grafting. It was possible to use arterial conduits in all the patients, even in those with impaired left ventricular function.

Off-pump coronary operation at the Favaloro Foundation: results in 264 patients.

BACKGROUND: Our objective was to determine whether complete myocardial revascularization "off pump" was feasible while maintaining the efficacy of conventional surgical techniques. METHODS: 264 patients were operated on between March 15, 1998, and August 26, 1999. A total of 218 (82.6%) were men and the average age was 61.4 years (range 28 to 87 years). Left main occlusions were present in 10.2% and 84% had multiple vessel disease. A total of 628 grafts were implanted, an average of 2.4 grafts per patient. Total arterial revascularization was achieved in 81.5% using both internal mammary arteries and the radial artery, one or more venous grafts in 18.1%, and venous alone in 0.3%. RESULTS: Surgical mortality was 2.2% and perioperative myocardial infarction was 3%. There were no neurologic events in this group of patients. In the first 73 patients coronary angiography control was performed before discharge and all grafts were patent. Angioplasty was carried out in 2 patients (0.76%) and conversion of procedure in 4 (1.5%). Follow-up time was 4 to 14 months. CONCLUSIONS: This procedure enabled revascularization of all areas of the heart, usually with total arterial revascularization, and excellent patency rates. The morbidity and mortality observed was similar to conventional surgery. The incidence of secondary complications (bleeding, need for transfusion, prolonged mechanical ventilation, or neurologic events) was lower.

[Coronary revascularization surgery with arterial conduits. The technic, results and 4-year follow-up in 1023 consecutive patients]. / Cirugía de revascularización coronaria con conductos arteriales. Técnica, resultados y seguimiento a cuatro años en 1,023 pacientes consecutivos.

OBJECTIVE: The main objective of the present study was to analyze the in-hospital and mid term results obtained in 1,023 consecutive patients undergoing coronary artery bypass surgery (CABG) in whom a combination of arterial grafts was used: radial arteries (RA) and one or both internal mammary arteries (IMA). METHODS: From May 1995 to May 1998, 1,023 consecutive patients underwent CABG alone, using arterial conduits (AC) (one or two IMA and RA) for myocardial revascularization. The left internal mammary artery (LIMA) was employed as an "in situ" graft, and the right internal mammary artery (RIMA) as a free graft or "in situ" both in combination with the RA. The latter was connected to the LIMA through a T or Y anastomosis, or emerged directly from the ascending portion of the aorta. RESULTS: An average of 3.2 bypasses per patient were performed. The LIMA was used in 100% of the patients. The RIMA was used in 21.7% and the RA in 100% of the cases. Operative mortality was 2.5% (26 patients) and 32 (3.1%) suffered perioperative acute myocardial infarction. The first 62 patients were angiographically re-studied before discharge, and a 98.4% patency of the AC used was found. Mean follow up time was 25.0 +/- 9.6 months (range, 1 to 48 months). CONCLUSIONS: a) myocardial revascularization procedures using a combination of mammary and RA grafts are safe; b) in-hospital and mid term morbidity and mortality are not higher than those observed with saphenous vein grafts; c) it is possible to achieve complete myocardial revascularization with only AC, even in patients with impaired left ventricular function, and d) AC can be used in elderly patients.

[Atrioventricular node catheter ablation with condenser discharge and radiofrequency]. / Ablación del nódulo atrioventricular con descarga de condensadores y radiofrecuencia.

The AV junction ablation was useful to treat patients with drug-refractory supraventricular arrhythmias. The purpose of this study was to determine short and long-term success and complications of the atrioventricular nodal catheter ablation and to compare direct current and radiofrequency energy. Forty patients underwent AV nodal ablation with direct current energy (Group I) and forty patients with radiofrequency (Group II). They were followed up for a mean of 76 +/- 49 and 28 +/- 20 months, respectively. Persistent complete AV block was successfully induced during the first ablation session in 45% of 40 patients who underwent DC energy, while in 50% it was modulated. All patients in the radiofrequency group had complete AV block. The rate of recurrence of AV conduction was 7.5% and 2.5% respectively. Immediate complications did not occur after either procedure. One patient died suddenly in each group during follow-up. AV nodal ablation with radiofrequency energy appears to be as efficacious and safe as direct current energy.

Deep hypothermia and circulatory arrest as an elective technique in the treatment of type B dissecting aneurysm of the aorta.

The combination of deep hypothermia and circulatory arrest has been used in a variety of cardiovascular surgical techniques and is presented in this article as an elective method in the treatment of type B dissecting aneurysms that may or may not involve the distal aortic arch. Out of 190 patients operated on with acute aortic dissection, 10 patients with type B underwent surgical procedures, between January 1985 and December 1987, four with acute dissection (less than 14 days evolution), and six with chronic dissection (more than 14 days evolution). The approach was by left posterolateral thoracotomy with cardiopulmonary bypass using femoro-femoral cannulation, deep hypothermia, and circulatory arrest. The duration of circulatory arrest was between 27 and 58 minutes, mean 37 minutes. Extracorporeal circulation (ECC) lasted between 68 and 142 minutes, with a mean perfusion time of 83.7 minutes, and temperature fell to 14 degrees C and 16 degrees C. Intrahospital mortality was 20% (two patients). No long-term mortality has been recorded. Eighty percent of the patients (eight patients) are alive and showed good evolution between 10 and 44 months following surgery, with a long-term mean survival of 24 months and 23 days. The only neurological complication was a single case of right unilateral blindness followed by complete visual recuperation. Myocardial and spinal cord protection are excellent, without any incidence of postoperative infarct or paraplegia. Postsurgical blood loss ranged from 200 to 650 mL with a mean of 385 mL. Acute renal insufficiency was not detected. We believe that the combined techniques of deep hypothermia and circulatory arrest used electively, and not just out of occasional necessity, is a viable choice that allows easier surgical manipulation of type B dissection aneurysms and complete resolution of those involving retrograde dissection to the aortic arch. In addition. this combined technique does not increase postoperative mortality in this critically dangerous disease.