Left internal mammary artery improves 5-year survival in patients under 40 subjected to surgical revascularization.

BACKGROUND: The population of young patients under 40 requiring coronary bypass surgery is characterized by an extremely and unusually rapid progression of coronary heart disease. The aim of the present study was to assess the clinical status and quality of life in these patients after surgery in relation to the type of conduit used to revascularize the left anterior descending artery (LAD). METHODS: One hundred seventeen patients under 40 (range, 30-40 years) underwent coronary artery bypass grafting (CABG) at our institution between 1991 and 1999. Ninety-one patients received LIMA to LAD graft (group A), and in 26 patients the saphenous vein was used to graft this vessel (group B). Seventy-eight patients (63 in group A and 15 in group B) were assessed after a mean time of 71 +/- 26 months. They were asked to fill out a questionnaire aimed at their subjective assessment of their quality of life as compared with their preoperative status. RESULTS: Five-year actuarial survival was higher in patients with LIMA to LAD graft (log rank test: P < .004). The functional status of patients in group B was significantly worse in comparison to group A: respectively, CCS 2.2 +/- 1.1 versus 1.5 +/- 0.7; (P = .02), NYHA 2.2 +/- 1.1 versus 1.3 +/- 0.5; (P = .002). Patients in group B more frequently required reinstitution of nitroglycerine treatment (93% versus 56%; P = .025). We failed to show differences between the 2 groups as far as subjective quality of life is concerned. In summary, 63% of patients perceived it to be worse, 29% to be better, and 8% felt it had not changed. CONCLUSION: The use of LIMA is crucial in patients undergoing CABG under the age of 40 in order to achieve the best possible surgical results. Quicker recurrence of coronary disease symptoms is observed when a vein is used to graft the LAD. It may reflect an earlier progress of atherosclerosis in venous grafts.

[Mediastinal abscess as a remote complication of CABG combined with temporary cardiac pacing--a case report]. / Ropien sródpiersia jako odlegle powiklanie pomostowania tetnic wiencowych z zastosowaniem czasowej stymulacji serca. Opis przypadku.

A case of a 74 year old patient with a history of CABG with temporary epicardial cardiac pacing, is described. Five years later the patient developed wound infection. Computerised tomography revealed the presence of mediastinal abscess containing surgical material. The patients underwent surgical removal of the abscess with a distal part of an epicardial pacing lead which was left after CABG and was the most probable cause of infection.

Angiotensin-converting enzyme inhibitors reveal non-NO-, non-prostacycline-mediated endothelium-dependent relaxation in internal thoracic artery of hypertensive patients.

BACKGROUND: We have shown that treatment of hypertension with ACE inhibitors (ACE-I) enhances relaxation to acetylcholine in human internal thoracic artery (ITA) above this in nonhypertensive patients receiving no ACE-I. Present study assesses the endothelium-dependent responses mediated by neither NO nor prostacyclin in human ITA. METHODS: We compared isolated ITA rings from hypertensive patients treated with ACE-I (ACE-I group) with those from normotensive patients on no ACE-I (control group). Relaxation to acetylcholine was assessed before and after inhibition of NO synthase and cyclooxygenase with L-NMMA and indomethacin, respectively. RESULTS: The maximal relaxation in ACE-I group was 79+/-3.3% and was depressed by incubation with L-NMMA and indomethacin to 41+/-2.7% (p<0.001); pD(2)=7.7+/-0.1 vs. 7.4+/-0.8 (p=0.265). The maximal relaxation to acetylcholine was lower in the control group: 65+/-3.3% (p=0.01); pD(2)=7.5+/-0.1 (p=0.07). Incubation with L-NMMA and indomethacin produced contraction to acetylcholine with a maximum of 43+/-7% (p<0.001); pD(2)=5.3+/-0.3 (p<0.001). The area under the concentration-response curve for acetylcholine-induced relaxation in ACE-I group equaled [arbitrary units] 596+/-71 and after incubation with L-NMMA and indomethacin 281+/-40 (p=0.002). Estimated LNMMA- and indomethacin-resistant relaxation, absent in control group, accounted for 47+/-4% of relaxation to acetylcholine in ACE-I group. Estimated NO- and prostacyclin-mediated relaxation was higher in control group than ACE-I group: 628+/-74 vs. 315+/-47 (p=0.009). CONCLUSIONS: The results suggest that therapy with ACE-I improves endothelial function of hypertensive patients mainly by enhancing the endothelium-derived hyperpolarizing factor (EDHF) (and not NO)-mediated responses. It seems that it reveals measurable non-NO- non-PGI-mediated endothelium-dependent relaxation otherwise absent in conduit arteries.

Minimally invasive mitral valve surgery -- first experience in Poland.

BACKGROUND: Minimally invasive cardiac surgery has been introduced to treat various cardiac disorders, predominantly ischaemic heart disease. Its usage in valvular disorders has been only recently proposed. AIM: To assess safety and efficacy of minimally invasive mitral valve surgery. METHODS: The procedure was performed in 10 patients (6 females, 4 males, mean age 59+/-7 years). All but one had preserved left ventricular ejection fraction. Two patients underwent mitral valvuloplasty, and mitral valve replacement was performed in all remaining cases. One procedure was a redo surgery following mitral commisurotomy. RESULTS: In all patients the procedure was effective. Prolongation of cardiopulmonary bypass and aorta cross-clamping time did not increase the complication rate which included one wound infection, one repeated cannulation of the femoral vessels and one minor stroke. Rehabilitation process seemed to be shorter than after standard procedures. CONCLUSIONS: Minimally invasive mitral valve surgery is a safe and alternative method of treatment, and is associated with excellent cosmetic results.

Total arterial revascularization for multiple vessel coronary artery disease: with or without cardiopulmonary bypass.

BACKGROUND: To assess the usefulness of off-pump technique for more technically demanding coronary artery bypass procedures using exclusively arterial conduits. METHODS: Analysis of perioperative data of 324 consecutive patients in whom total arterial revascularization for multiple- vessel coronary artery disease was performed--181 cases on-pump and 143 cases off-pump. RESULTS: On average in the on-pump group 2.7 +/- 0.8 (range, 2-5) grafts per patient were constructed versus 2.4 +/- 0.7 (range, 2-4) grafts per patient in the off-pump group (P < .001). Of the total number of 490 anastomoses performed on-pump, 83 (17%) were side-to-side and of 349 anastomoses performed off-pump, 51(15%) were side-to-side, a nonsignificant difference (P = .4). The aorta was used as a site for proximal anastomosis of 1 or more arterial conduits in 105 patients (58%) who underwent on-pump surgery and in 57 patients (40%) who underwent off-pump surgery (P = .002). In the off-pump group, the right internal thoracic artery (RITA) was rarely (12%) routed through the transverse sinus to circumflex branches compared with the on-pump group (34%) (P = .017). RITA in off-pump patients was more often used to revascularize the anterior wall (47% versus 29%; P = .08). We observed no difference in mortality (1.7% versus 0%; P = .3), incidence of perioperative myocardial infarction (8.8% versus 7.7%; P = .8), stroke (1.7% versus 1.4%; P = .8), or atrial fibrillation (24% versus 19%; P = .3). We observed less inotropic support and less blood-product use in off-pump patients. CONCLUSION: Total arterial revascularization for multiple-vessel coronary artery disease may be safely performed off-pump. We observed tendency to somewhat smoother postoperative course in the off-pump group.

[Management of purulent mediastinitis with sternal dehiscence - a case report]. / Leczenie ropnego zapalenia sródpiersia z niestabilnoscia mostka - opis przypadku.

The authors report the case of 70-year-old female who underwent urgent CABG for unstable angina. The post-operative course was complicated by Staphylococcal mediastinitis, which was treated with chest irrigation system and antibiotics. Because of extensive tissue destruction caused by the infection, the steel sternal wires were not placed. Interestingly, one year after surgery the sternal wound was completely healed and there were no paradoxical respiratory movements.