Frequency of Deep Vein Thrombosis and/or Pulmonary Embolism After Coronary Artery Bypass Grafting Investigation Regardless of Clinical Suspicion.

Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Many surgeons and clinicians believe that VTE after coronary artery bypass grafting (CABG) has little clinical significance because it is seldom diagnosed. This study aimed to identify VTE after CABG, independent of clinical suspicion. In this prospective, observational, single-center study, 100 patients underwent computed tomographic pulmonary angiography (multidetector-64) and lower extremity venous compressive ultrasound after elective CABG. Patients with high risk for VTE were excluded. Aspirin was maintained throughout the preoperative and postoperative periods, and early ambulation was encouraged. Postoperatively, no mechanical or heparin prophylaxis was used in any patients. At the discretion of the surgeons, 83 surgeries were on-pump, and 17 were off-pump. On average, tomography and ultrasound were performed 7 ± 3 days after CABG. Isolated PE was observed in 13 of 100 patients (13%), simultaneous PE and DVT in 8 of 100 (8%), and isolated DVT in 4 of 100 (4%), thus totaling 25/100 VTEs (25%). Of the 21 PEs, 3 of 21 (14%) involved subsegmental, 15 of 21 (71%) segmental, 1 of 21 (5%) lobar, and 2 of 21 (10%) central pulmonary arteries. Of the 12 DVTs, all were distal (below the popliteal vein), and 2 of 12 (17%) were also proximal; 5 of 12 (42%) were unilateral, of which 3 of 5 (60%) on the contralateral saphenous vein-harvested leg. No VTE caused hemodynamic instability, and none was clinically suspected. In conclusion, VTEs were frequent, some extensive proximal VTEs occurred, but most were distally localized. Many patients in this series would have been discharged without diagnosis of and treatment for PE and/or DVT.

The descending branch of the lateral femoral circumflex artery is a good option in CABG with arterial grafts.

INTRODUCTION: The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. OBJECTIVE: To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. METHODS: Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P<0.05). RESULTS: Descending branch of the lateral femoral circumflex artery wDescending branch of the lateral femoral circumflex artery was used in 26 patients, as its use was not viable in six patients (18%). It was used as composite graft in all cases. The anterior descending branch was revascularized by the left internal thoracic artery in all cases. Patency rates of the descending branch of the lateral femoral circumflex artery were 96% and 92%, respectively. No occlusions were observed in the left internal thoracic artery (LITA) and no ischemic events were observed in the descending branch of the lateral circumflex. Descending branch of the lateral femoral circumflex artery increased the lumen diameter in the middle (P=0.001) and distal portions (P=0.006); the left internal thoracic artery (LITA) increased in the middle portion (P=0.001). CONCLUSION: Similar to the left internal thoracic artery, the descending branch of the lateral femoral circumflex artery showed high patency rate and positive luminal adaptation. This early evaluation confirms the descending branch of the lateral femoral circumflex artery as a potential alternative for grafting. Due to anatomical variations, preoperative femoral angiographic evaluation appears to be mandatory.

The descending branch of the lateral femoral circumflex artery is a good option in CABG with arterial grafts / Ramo descendente da artéria circunflexa lateral femoral é boa opção para revascularização do miocárdio com enxertos arteriais

INTRODUCTION: The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. OBJECTIVE: To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. METHODS: Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P<0.05). RESULTS: Descending branch of the lateral femoral circumflex artery wDescending branch of the lateral femoral circumflex artery was used in 26 patients, as its use was not viable in six patients (18%). It was used as composite graft in all cases. The anterior descending branch was revascularized by the left internal thoracic artery in all cases. Patency rates of the descending branch of the lateral femoral circumflex artery were 96% and 92%, respectively. No occlusions were observed in the left internal thoracic artery (LITA) and no ischemic events were observed in the descending branch of the lateral circumflex. Descending branch of the lateral femoral circumflex artery increased the lumen diameter in the middle (P=0.001) and distal portions (P=0.006); the left internal thoracic artery (LITA) increased in the middle portion (P=0.001). CONCLUSION: Similar to the left internal thoracic artery, the descending branch of the lateral femoral circumflex artery showed high patency rate and positive luminal adaptation. This early evaluation confirms the descending branch of the lateral femoral circumflex artery as a potential alternative for grafting. Due to anatomical variations, preoperative femoral angiographic evaluation appears to be mandatory.

INTRODUÇÃO: O ramo descendente da artéria circunflexa lateral é um enxerto pouco avaliado e pode ser uma opção para a revascularização do miocárdio. OBJETIVO: Avaliar a perviabilidade e o remodelamento arterial do ramo descendente da artéria circunflexa lateral, em três meses de seguimento, por meio de angiotomografia de artérias coronárias. MÉTODOS: Foram analisados 32 pacientes submetidos à revascularização do miocárdio com ramo descendente da artéria circunflexa lateral, artéria torácica interna esquerda e outros enxertos. A avaliação foi realizada por meio da tomografia computadorizada de alta resolução, realizada no 7º e 90º dias de pós-operatório. O diâmetro do ramo descendente da artéria circunflexa lateral foi medido 3 cm antes da anastomose distal, na porção média e 3 cm após a anastomose proximal. As mesmas medidas foram realizadas para a artéria torácica interna esquerda. Os diâmetros foram comparados pelo método t de Student pareado (significância P<0,05). RESULTADOS: O ramo descendente da artéria circunflexa lateral foi adequado para a utilização em 26 pacientes. Em seis (18%) pacientes, o ramo descendente da artéria circunflexa lateral era inviável. Em todos os casos, o ramo descendente da artéria circunflexa lateral foi empregado sob a forma de enxerto composto. Todos os pacientes receberam artéria torácica interna esquerda para o ramo descendente anterior. A perviabilidade do ramo descendente da artéria circunflexa lateral foi de 96% e 92%, em 7 e 90 dias de pós-operatório, respectivamente. Não foram detectadas oclusões da artéria torácica interna esquerda. Não foram detectados sinais de espasmo do ramo descendente da artéria circunflexa lateral. O ramo descendente da artéria circunflexa lateral apresentou aumento de diâmetro nas porções média (P=0,001) e distal (P=0,006) e a artéria torácica interna esquerda, aumento na porção média (P=0,001). CONCLUSÃO: O remodelamento positivo sugere que o ramo descendente da artéria circunflexa lateral tem comportamento semelhante à artéria torácica interna esquerda e pode ser uma excelente opção para a revascularização do miocárdio com enxertos arteriais. Em virtude das variações anatômicas, estudos de pré-operatório podem auxiliar na seleção de casos.

Holt-Oram syndrome: novel TBX5 mutation and associated anomalous right coronary artery.

The Holt-Oram syndrome was confirmed in an asymptomatic 36-year-old man by a novel TBX5-gene mutation (exon 8 acceptor splicing site, c.663-1G greater than A). Computed tomography showed an atrial septal defect and an anomalous right coronary artery crossing between the aorta and pulmonary arteries. Surgery corrected the septal defect and the initial segment of the anomalous vessel was unroofed and enlarged. Anomalous coronary arteries were not previously described in the Holt-Oram syndrome patients and should be added to the list of possible associated cardiac defects.

Left ventricular systolic function and outcome after in-hospital cardiac arrest.

BACKGROUND: The effect of prearrest left ventricular ejection fraction (LVEF) on outcome after cardiac arrest is unknown. METHODS AND RESULTS: During a 26-month period, Utstein-style data were prospectively collected on 800 consecutive inpatient adult index cardiac arrests in an observational, single-center study at a tertiary cardiac care hospital. Prearrest echocardiograms were performed on 613 patients (77%) at 11+/-14 days before the cardiac arrest. Outcomes among patients with normal or nearly normal prearrest LVEF (> or = 45%) were compared with those of patients with moderate or severe dysfunction (LVEF < 45%) by chi(2) and logistic regression analyses. Survival to discharge was 19% in patients with normal or nearly normal LVEF compared with 8% in those with moderate or severe dysfunction (adjusted odds ratio, 4.8; 95% confidence interval, 2.3 to 9.9; P<0.001) but did not differ with regard to sustained return of spontaneous circulation (59% versus 56%; P=0.468) or 24-hour survival (39% versus 36%; P=0.550). Postarrest echocardiograms were performed on 84 patients within 72 hours after the index cardiac arrest; the LVEF decreased 25% in those with normal or nearly normal prearrest LVEF (60+/-9% to 45+/-14%; P<0.001) and decreased 26% in those with moderate or severe dysfunction (31+/-7% to 23+/-6%, P<0.001). For all patients, prearrest beta-blocker treatment was associated with higher survival to discharge (33% versus 8%; adjusted odds ratio, 3.9; 95% confidence interval, 1.8 to 8.2; P<0.001). CONCLUSIONS: Moderate and severe prearrest left ventricular systolic dysfunction was associated with substantially lower rates of survival to hospital discharge compared with normal or nearly normal function.

Monophasic versus biphasic waveform shocks for atrial fibrillation cardioversion in patients with concomitant amiodarone therapy.

AIMS: With transthoracic cardioversion of atrial fibrillation (AF), biphasic are more effective than monophasic waveforms. We sought to determine the ideal energy levels for biphasic waveforms. Methods We compared biphasic truncated exponential waveforms with monophasic damped sine waveform defibrillators, in a prospective, single-centre, randomized (1:1 ratio) study. The study included 154 patients receiving concomitant amiodarone; 77 received serial biphasic (50, 100, 150, up to 175 J) and 77 monophasic shocks (100, 200, 300, up to 360 J), as necessary. Results First-shock efficacy was similar in the two groups (57 vs. 55%, P = 0.871, respectively), as were serial-shocks (90 vs. 92%, P = 0.780). Both groups received equal numbers of shocks (1.8 +/- 1.1 vs. 1.7 +/- 1.0, P = 0.921). In both groups, serum creatine kinase levels showed a small but significant increase. The increase was, however, higher in the monophasic group. CONCLUSION: In patients with concomitant amiodarone therapy, biphasic truncated exponential shocks, using half the energy, were as effective as monophasic damped sine shocks. The biphasic scheme was not more efficacious for cardioverting AF. In our population, a first shock of at least 100 J seemed advisable with either waveform. If necessary, escalating shocks must be performed, but ideal levels of increase per shock are still uncertain for biphasic waveforms.

Spontaneous aortic dissection limited to sinus of Valsalva and involving the left main coronary artery.

Aortic dissection limited to one sinus of Valsalva has been described exclusively as an iatrogenic complication during catheterization interventions. This life-threatening subtype had a very small area of dissection, when coronary ostia are frequently involved. We report a 43-year-old man with dissection limited to left sinus of Valsalva, involving the left main coronary artery and causing non-ST-myocardial infarction, including severe reversible ST-depression, maximum of 9 mm in V5 lead. Dissection was suggested by cineangiography, transesophageal echocardiogram, and contrast-enhanced multidetector computed tomography. Surgical treatment was successful. There were not any associated diseases in the sinuses of Valsalsa, aortic valve or coronary arteries. Unlike previous reported cases of aortic dissection with such limited localization, the present case was spontaneous, and not iatrogenic.

Myocardial bridging causing transmural ischemia. Successful coronary artery bypass surgery.

Myocardial bridging is a common and usually benign inborn coronary anomaly. We report on a 51-year-old man who presented with recent angina on minimum physical effort. Cineangiography showed myocardial bridging of the mid-left anterior descending artery (LAD), and intracoronary ultrasonography excluded atherosclerotic disease. Gated single-photon emission computed tomography (SPECT), with exercise stress, showed an extensive anterior perfusion defect, and remarkable ST-segment elevation (up to 10 mm) in recovery. Vasospasm of the LAD was the main hypothesis. Additional oral drugs did not bring about improvement, as indicated on a new SPECT; disabling angina persisted. Surgical revascularization of the LAD by left internal mammary artery graft was performed. Two years later, SPECT and exercise tests returned to normal. The patient remains asymptomatic.

Effects of growth hormone replacement therapy on metabolic and cardiac parameters, in adult patients with childhood-onset growth hormone deficiency.

OBJECTIVE: We evaluated metabolic and cardiac parameter changes with GH-therapy. DESIGN: Sixteen adults with childhood-onset hypopituitarism receiving pituitary hormone replacement, except GH-replacement, were assessed at baseline and after 6 and 12 months of GH-replacement. Sixteen healthy adults matched for sex, age, weight, height, body mass index, and body surface area served as the control group to compare cardiac function in both groups. RESULTS: All patients had GH-deficiency. After 12 months, serum insulin-like growth factor-1 levels normalized. Basal glucose or insulin levels had no alterations. The low/high density lipoprotein-cholesterol ratio decreased (3.18+/-1.32 x 2.17+/-0.8, p<0.001). Percent lean body mass increased (69.9+/-5.5 x 78.4+/-8.1%), and percent fat body mass decreased (30.1+/-5.5 x 21.6+/-8.1%) (both, p<0.001). Before treatment, patients had decreased left ventricular (LV) echocardiographic morphologic indexes, which were corrected (initial versus 12 months): interventricular septal thickness (0.68+/-0.06 x 0.78+/-0.06 cm), LV posterior wall thickness (0.69+/-0.07 x 0.78+/-0.05 cm), and LV mass index (58.9+/-11.0 x 71.1+/-9.4 g/m(2)) (all, p<0.001). Exercise capacity improved, as assessed by oxygen consumption (7.84+/-1.44 x 9.67+/-1.74 METS, p<0.001). CONCLUSIONS: GH-replacement seems to reduce cardiovascular risks in adults with childhood-onset GH-deficiency.

Treatment of acromegaly improves myocardial abnormalities.

BACKGROUND: Treatment for acromegaly decreases left ventricular (LV) mass, but it is not clear whether diastolic dysfunction is also reversible. With Doppler echocardiography, before and after effective therapy, we assessed the LV morphology and function of patients with acromegaly who were free of complications. METHODS: In 15 patients with active acromegaly (age range, 33.4 +/- 9.3 years), we compared LV Doppler echocardiographic indices, before and after transsphenoidal surgery or radiotherapy or before and after both procedures, noting a significant drop in plasma levels of growth hormone (<2.0 ng/mL after oral glucose tolerance testing). Patients did not have arterial hypertension, diabetes mellitus, thyroid dysfunction, or coronary artery disease. Occasionally, in this series, patients had no symptoms of heart failure, and patients who underwent treatment with somatostatin analog drugs were not included because they did not have a significant hormonal drop. The follow-up period after hormonal control was 2.7 +/- 1.7 years. We also studied 15 healthy control subjects matched for age, sex, and body surface area. RESULTS: Patients with acromegaly compared with healthy control subjects had increased LV mass index, relative wall thickness, and deteriorated diastolic function. After therapy, most of the abnormalities improved: LV mass index (104 +/- 21 g/m(2) x 87 +/- 21 g/m(2); P <.01), LV relative wall thickness (0.40 +/- 0.06 x 0.35 +/- 0.04; P <.01), proto/telediastolic transmitral peak flow velocity ratio (1.17 +/- 0.33 x 1.49 +/- 0.34; P <.001), and isovolumetric relaxation period (126 +/- 18 ms x 113 +/- 13 ms; P <.05). CONCLUSION: Treatment of acromegaly in patients without clinical heart failure improves both LV morphology and diastolic function. Avoidance of progression to more advanced forms of acromegalic cardiomyopathy should be possible.