Intermittent warm blood versus cold crystalloid cardioplegia for myocardial protection: a propensity score-matched analysis of 12-year single-center experience.

OBJECTIVES: This study analyzes the efficacy in myocardial protection of two types of cardioplegia solutions, namely, blood and crystalloid cardioplegia, both given intermittently in patients undergoing coronary artery bypass grafting (CABG). METHODS: Adult patients undergoing primary isolated coronary artery bypass grafting between January 1998 and January 2011 with cardiopulmonary bypass, using either blood or crystalloid cardioplegia, were identified in our database. Propensity score matching was performed to create comparable patient groups. Multivariate logistic regression analysis was performed to identify independent risk factors for perioperative myocardial damage. The primary endpoint of the study was the maximum creatine kinase-MB (CK-MB) value within 5 days postoperatively with a cut-off point of 100 U/L. Early mortality and perioperative low cardiac output syndrome in both groups were compared. RESULTS: The study included 7138 CABG patients: 3369 patients using crystalloid cardioplegia and 3769 using blood cardioplegia. After propensity score matching, 2585 patients per study group remained for the analysis. Wilcoxon signed-rank test revealed significantly higher CK-MB levels in patients operated with the use of blood cardioplegia. Multivariate regression analysis identified blood cardioplegia as an independent risk factor for elevated CK-MB levels. However, it was associated with lower aspartate aminotransferase (AST) levels. The type of cardioplegia had no influence on early mortality, postoperative low cardiac output syndrome or intensive care unit stay. CONCLUSIONS: Blood cardioplegia was identified as an independent risk factor for elevated levels of CK-MB after CABG, but was associated with lower AST levels. The authors conclude that the type of cardioplegia had no significant influence on clinical outcome.

Preoperative therapy of low-dose aspirin in internal mammary artery bypass operations with and without low-dose aprotinin.

The effect of preoperative low-dose aspirin (1 mg/kg of body weight) and intraoperative low-dose aprotinin (2 million kallikrein inactivator units) treatment on perioperative blood loss and blood requirements in patients who undergo internal mammary artery bypass operations is unknown. Therefore, we retrospectively studied 75 matching patients who underwent internal mammary artery operations, and they were allocated to one of three groups: low-dose aspirin and aprotinin treatment (group 1, n = 25), low-dose aspirin treatment without aprotinin (group 2, n = 25), and neither aspirin nor aprotinin treatment (group 3, n = 25). Although the perioperative blood loss was similar, the blood requirements tended to be higher (p = 0.09) in the patients who were treated with aspirin (group 2) than in the control patients (group 3). When aprotinin was added to the priming solution in patients who were treated with aspirin (group 1), blood loss was significantly lower (p < 0.05) than that of group 2 patients but not of control patients. Blood requirements were significantly lower (p < 0.01) than those of patients in groups 2 and 3. Blood products were needed in 29%, 62%, and 75% of patients in groups 1, 2, and 3, respectively.

Intraoperative blood flow measurement of the right gastroepiploic artery using pulsed Doppler echocardiography.

BACKGROUND: In coronary artery revascularization, the right gastroepiploic artery (GEA) has become the third arterial conduit of choice after both internal thoracic arteries. To evaluate the function of the right GEA, we used intraoperative ultrasonographic Doppler measurement of the blood flow of this artery. METHODS: From November 1992 to December 1993, in 41 consecutive patients, graft flow velocity, diameter, and blood flow were measured in the proximal part of the GEA before takedown and after completion of the anastomosis just before sternal closure. We also analyzed the predictors of postoperative ischemia. RESULTS: Flow volume of the GEA after anastomosis with the coronary artery has a significant correlation with the diameter of the target coronary artery (p = 0.0011). Two patients had development of ischemia postoperatively. In both, volume flow of the GEA was less than 25 mL/min before takedown compared with an average flow of 55.78 mL/min in the patients without ischemia postoperatively. This was found to be a prognostic indicator of poor graft performance with consequent ischemia. CONCLUSIONS: When the GEA blood flow volume before takedown is less than 25 mL/min, we suggest that this artery not be used as a bypass graft for myocardial revascularization.

Combined superior-transseptal approach to the left atrium.

The combined superior-transseptal approach to the left atrium was used in 22 patients: to perform a mitral valve repair in 14 patients and mitral valve replacement in 8 patients. Mitral valve operation was combined with other cardiac procedures in 18 patients (82%) and was performed as a reoperation in 3 patients (14%). In all cases there was excellent exposure of the complete mitral annulus and subvalvar apparatus. There were no instances of postoperative bleeding, conduction defects, or intraatrial shunting related to the approach. The combined superior-transseptal approach to the left atrium is an excellent approach that can be used in most reoperations and primary procedures for isolated or combined mitral valve operations.

Noninvasive assessment of coronary flow reserve in the right gastroepiploic artery graft.

BACKGROUND: To investigate the functional capacity of the right gastroepiploic artery graft (GEA) and its ability to adapt to provide adequate flow at peak myocardial demand, we investigated the feasibility of determining coronary flow reserve (CFR) provided by this vessel using transabdominal color Doppler echocardiography and the correlation between this noninvasive determination of flow reserve and nuclear stress scintigraphy. METHODS: In 40 selected patients, who underwent complete arterial myocardial revascularization using the GEA and the internal thoracic arteries (ITAs), CFR of the GEA was measured at maximum coronary hyperemia induced by intravenous adenosine infusion, 7 months (range 3 to 20) after surgery. In the same period, in 31 of this group of patients, exercise thallium scintigraphy was performed. RESULTS: We succeeded in measuring CFR in 37 of 40 patients with values ranging from 1.1 to 3.6 with an average of 2.1 +/- 0.7. During adenosine infusion, mean velocity in the GEA significantly increased from 48 +/- 20 to 89 +/- 41 cm/sec (p < 0.001), mean arterial blood pressure significantly decreased from 96 +/- 11 to 87 +/- 11 mm Hg (p < 0.001), and heart rate significantly increased from 74 +/- 11 to 87 +/- 15 beats/min (p < 0.001). In 8 of these 37 patients, the nuclear exercise test was positive (compatible with reversible ischemia in the distribution area of the GEA). Average CFR in these 8 patients with positive nuclear stress test was 1.46 +/- 0.28 versus 2.27 +/- 0.70 in those patients with a negative test (p < 0.001). CONCLUSIONS: Noninvasive determination of CFR of GEAs is feasible, using transabdominal Doppler echocardiography. The present study shows that coronary vasodilator reserve and autoregulation is maintained in myocardium supplied by the GEA and that the CFR has a significant correlation with the results of noninvasive nuclear exercise testing. Therefore, noninvasive determination of CFR by transabdominal Doppler echocardiography might be a valuable contribution to functional assessment of GEAs.

Cardiogenic shock due to coronary narrowings one day after a MAZE III procedure.

A MAZE III procedure was performed on a patient with a small body surface area. On the first postoperative day, the patient developed severe dysfunction of the left ventricle, due to significant narrowings of the right and circumflex coronary arteries in the areas that were cryoablated during the MAZE III procedure. The coronary narrowings were treated by percutaneous transluminal coronary angioplasty (PTCA). At discharge the coronary anatomy was normal again with an almost normal left ventricular function.

Myocardial protection with cold cardioplegia in a patient with cold autoagglutinins and hemolysins.

A technique is described for providing myocardial protection with cold potassium crystalloid cardioplegia in a patient with cold autoagglutinins and hemolysins. The patient was only mildly cooled systemically. The coronary system was perfused with a normothermic cardioplegic solution to remove the blood before the cold cardioplegia was started. The heart was rewarmed with a normothermic cardioplegic solution before the blood was reintroduced. With this technique, the patient underwent an uneventful coronary bypass operation.

Noninvasive assessment of right gastroepiploic artery graft patency using transcutaneous color Doppler echocardiography.

BACKGROUND: Because the right gastroepiploic artery graft (GEA), when routed antegastrically, is situated just behind the abdominal wall, we investigated the possibility of evaluating graft patency and flow characteristics using transabdominal color Doppler echocardiography. METHODS: The right GEA graft was evaluated in 71 patients who underwent complete arterial revascularization, 4 months (range, 2 to 17 months) postoperatively. Selective angiography of the right GEA was performed in the patients in whom the graft could not be visualized using color Doppler echocardiography. RESULTS: Flow in the right GEA graft was detected in 65 (91.5%) of 71 patients using color Doppler echocardiography. In all visualized right GEAs, a biphasic flow pattern was observed, with higher peak velocity during systole. Mean (+/- standard deviation) peak systolic velocity was 76+/-16 cm/s. Mean (+/- standard deviation) velocity was 41+/-14 cm/s. Selective angiography of the right GEA in 5 patients in whom the graft could not be visualized using echocardiography showed four patent and functional grafts and one graft that was open but not functional ("slender sign"). One patient died before angiography could be performed. The sensitivity of noninvasive ultrasound assessment of the patency of the right GEA graft was 94% (65 of 69 patients). In this group of patients, an overall right GEA graft patency rate of 97% (69 of 71 patients) was found at mean follow-up of 4 months (range, 2 to 17 months). CONCLUSIONS: The right GEA graft is an adequate coronary artery graft with a good short-term patency rate, and transcutaneous color Doppler echocardiography is a useful tool for evaluating its patency and flow characteristics. Selective angiography of the right GEA can be avoided in most cases and is indicated only when the graft cannot be detected using Doppler echocardiography.

Similar hospital morbidity with the use of one or two internal thoracic arteries.

The hospital morbidity and mortality of 100 patients operated with two internal thoracic arteries with or without additional vein grafts (BITA group) were compared with a matched group of 100 patients operated with one left internal thoracic artery (ITA) on the anterior descending artery with additional vein grafts (LITA control group). In each study group, 3% of the patients had diabetes mellitus. There was no statistical significant difference in hospital mortality (1% versus 0%), perioperative myocardial infarction (5% versus 1%), low cardiac output (3% versus 5%), rethoracotomy (1% versus 0%), lung complications (13% versus 13%), wound complications (8% versus 8%), other cardiac complications (26% versus 16%), other noncardiac complications (1% versus 4%), median duration of stay in the intensive care unit (1 versus 1 day), and mean duration of stay in the hospital (10.4 versus 10.8 days) between the groups. Logistic regression analysis showed that the number of ITAs used was not a predictor of complications. Thus, there is no difference between the BITA and LITA control group in hospital mortality and morbidity (in patients with a low incidence of diabetes). If an improvement in cardiac event-free and reoperation-free survival is to be expected, the use of both ITAs can be continued in similar patients.

Low-dose aprotinin in internal mammary artery bypass operations contributes to important blood saving.

The effect on postoperative blood loss and blood use of blood-saving treatment with or without 280 mg of low-dose aprotinin (2 million kallikrein inactivator units) was studied in 200 consecutive patients undergoing either unilateral or bilateral internal mammary artery bypass grafting. Postoperative blood loss and total units of homologous blood products were similar in patients having either bypass procedure without aprotinin treatment. In patients given aprotinin, postoperative blood loss and use of homologous blood products were significantly lower (p < 0.05). The use of any donor blood product was prevented in 78% of the patients given aprotinin versus only 45% of patients treated without aprotinin. None of the aprotinin-treated patients underwent repeat thoracotomy for excessive bleeding; repeat thoracotomy was indicated in 8% of the patients having bilateral internal mammary artery grafting without aprotinin treatment. These results demonstrate that low-dose aprotinin reduces blood loss and blood use significantly and prevents excessive bleeding.

Better ischemic event-free survival after two internal thoracic artery grafts: 13 years of follow-up.

BACKGROUND: We researched our data to determine whether pedicled bilateral internal thoracic artery (BITA) grafting led to better ischemic event-free survival compared to single ITA grafting, at 10 years mean follow-up. METHODS: Retrospectively 249 patients with BITAs with or without additional vein grafts (BITA group) were matched with 233 comparable patients with left ITA and additional vein grafts (LITA group), at a mean follow-up interval of 10 years. RESULTS: At 13 years, 76.2% +/- 5.9% of the BITA and 78.3% +/- 3.8% of the LITA patients were still alive (p = not significant). Death, recurrent angina, new myocardial infarction, or coronary reinterventions occurred more often in LITA (49.4%) than BITA (33.3%) patients (p = 0.0004). The ischemic event-free survival estimates for BITA patients (47.5% +/- 8.4%) was better than for LITA patients (35.4% +/- 5.1%) (p < 0.001). Multivariate analysis showed that BITA was a predictor for ischemic event-free survival (p = 0.0005). CONCLUSIONS: For the decision to use one or two ITAs the positive influence of BITA grafting on ischemic event-free survival is more important than its effect on survival, per se. Compared to the general strategy of BITA grafting, neither total arterial revascularization nor the specific vessels grafted with BITA is relevant for the ischemic event-free survival.

Does it make sense to use two internal thoracic arteries?

Retrospectively, the first 143 patients who were operated on with bilateral internal thoracic arteries (BITA group) were matched with 143 patients operated on with only one left internal thoracic artery anastomosed on the left anterior descending artery and additional vein grafts (LITA group) and followed up for a maximum of 8 years. At 5 years follow-up there were no significant differences in event-free survival between the groups. After 8 years, the overall survival was 96% and 92% (not significant [NS]), cardiac survival 99% and 97% (NS), angina-free cardiac survival 51% and 35% (NS), infarction-free cardiac survival 95% and 78% (NS), reintervention-free cardiac survival 87% and 88% (NS), and all cardiac event-free survival 49% and 31% (NS) for the BITA and LITA groups, respectively. The incidence of late pulmonary, wound, and other complications was comparable. Cox proportional hazards analysis showed that a higher left ventricular end-diastolic pressure and female sex were predictors of recurrent angina and late cardiac events. During this intermediate-term follow-up, the use of one or two internal thoracic arteries was of no value in predicting angina-free or cardiac event-free survival.

Complete arterial myocardial revascularization using the right gastroepiploic artery and both internal thoracic arteries as pedicled grafts.

To achieve complete arterial myocardial revascularization without vein grafts, the right gastroepiploic artery and both internal thoracic arteries were used as pedicled grafts in 105 patients from March 1989 to July 1994. There were 101 male and 4 female patients, with a mean age of 51 years (range 32 to 65 years). Three-vessels disease was present in all patients. Six patients underwent previous bypass procedures with the use of vein grafts. A total of 363 distal anastomosis (108 with the right gastroepiploic artery, 255 with both internal thoracic arteries) were constructed. The mean number of distal anastomoses was 3.4. There was no hospital mortality. Seven patients required a rethoracotomy: 5 because of post-operative signs of ischemia, 2 because of bleeding. In one patient a splenectomy had to be performed because of bleeding. A new Q wave was noted in 2 patients. Follow-up averaged 21 months (range 1 to 67 months). Ninety nine (95%) of the patients were in NYHA class I, 6 (5%) in class II. No late complications were noted. We conclude that, complete myocardial revascularization using the right gastroepiploic artery in combination with both internal thoracic arteries as pedicled grafts can be achieved in selected patients with excellent mid term results.

An anatomical variation of the right gastroepiploic artery that excludes its use as a pedicled coronary bypass graft.

In an attempt to perform complete coronary revascularization with only arterial conduits in a 44 year-old male, both internal mammary arteries and the right gastroepiploic artery were harvested. The right gastroepiploic artery, however, showed an anatomical variation that excluded its use as a pedicled graft.

The Monostrut prosthetic valve. Predictors for valve-related events during an eight years' experience.

All postoperative complications, including transient ischaemic attacks (TIA) and cerebrovascular accidents (CVA) of 259 patients, in whom a total of 301 Monostrut tilting-disc valves were implanted between January 1985 and December 1991 were evaluated retrospectively. The follow-up was maximally 8 years, with a mean of 3.5 years, and totaled 914 patient-years. In this study we found no mechanical deterioration of the Monostrut valve and demonstrated the elimination of valve thrombosis in patients receiving adequate anticoagulation. The actuarial probability of being free of thrombo-embolism was 94.7% +/- 1.7% and free of anticoagulant related hemorrhage 95.4% +/- 1.5% at 8-years. In comparison with earlier reports by others, our findings show a lower ratio of thromboembolic and hemorrhagic events. We demonstrated a correlation (p < 0.05) between thrombo-embolic and hemorrhagic complications. In addition, a lower incidence of CVA's (0.22 per 100 patient-years), but a higher incidence of TIA's (0.66 per 100 patient-years) in comparison with the general Dutch population was found. At eight years follow-up, all patients were in Class I or II of the New York Heart Association Classification. Although the overall valve related event-free survival at eight years was only 47.9%, 93.5% of the patient were satisfied with their operative result. Predictive factors for late mortality were the occurrence of paravalvular leakage (p < 0.01), the age of the patient at the time of operation (p < 0.01) and the number of diseases coronary arteries (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of a blood conservation program including low-dose aprotinin in routine myocardial revascularization.

OBJECTIVES: We attempted to analyze the efficacy and safety of an extensive blood saving program applied in a large cohort of patients. MEASURES: Blood saving included reinfusion of intraoperative predonated blood, aprotinin (2 million KIU) in the prime solution, reinfusion of any residual volume, postoperative acceptance of normovolemic anemia (hematocrit > or = 25%) and autotransfusion of shed blood. SETTING, EXPERIMENTAL DESIGN AND PATIENTS: In our general hospital with a heart surgery service (1150 cases/year), we studied the records of 527 non-selected consecutive patients, who were prospectively treated with this program being applied in primary myocardial revascularization between. RESULTS: We avoided the use of donor blood in 86.9% of the patients requiring a mean of 0.2+/-0.01 unit of donor blood per patient. No repeat thoracotomy for bleeding was needed in any patient. Univariate analysis revealed that female gender, a low level of hematocrit, high age, a small stature, weight, body surface area, and red cell volume prebypass significantly (p<0.001) were correlated to treatment with donor blood. Multiple regression showed that a small red cell volume and a low prebypass hematocrit were the most (p<0.0001) significant predictors for the use of donor blood. Observing a low incidence of morbidity (myocardial infarction, gastrointestinal, neurological thromboembolic, renal and wound complications), the safety of this program seems to be emphasized. CONCLUSIONS: Extensive blood saving including low-dose aprotinin reduced effectively and safely the need for donor blood in a large cohort of patients.

Blood loss and use of blood in internal mammary artery and saphenous vein bypass grafting with and without adding a single, low-dose of aprotinin (2 million units) to the pump prime.

In comparison with saphenous vein bypass grafting (SVG) without a pleurotomy, internal mammary artery (IMA) bypass surgery might enhance more blood loss by the intrathoracic wound and a wide opened pleura. Low-dose aprotinin (Trasylol) reduces blood loss and consequently, the use of homologous blood. We studied the blood loss and blood requirements peri-operatively in 70 patients, who underwent either SVG-(n = 35) or IMA-surgery (n = 35) without aprotinin and another 70 patients who underwent SVG- (n = 35) or IMA-surgery (n = 35) with a single dose of aprotinin, added to the pump prime. We also determined the hemoglobin and total protein content of the shed blood. Without aprotinin administration, the mean intra-operative and post-operative blood loss was significantly less (p < 0.01) in SVG-patients, than in IMA-patients. We observed no statistical differences in the mean blood requirements between SVG- and IMA-surgery (1.2 units and 1.6 units). The use of any homologous blood product was similarly averted in 39% of the SVG-patients, and in 48% of the IMA-patients. Treatment with aprotinin significantly lessened (p < 0.01) the mean intra-operative blood loss only in IMA-patients. Post-operative blood loss was diminished with 45% in IMA-patients and 33% in SVG-patients, being significantly less (p < 0.01) after SVG, than after IMA-surgery. Blood requirements were significantly lowered (p < 0.01): a total mean of 0.2 units in SVG- and 0.6 units in IMA-patients (NS). Any homologous blood product was prevented in 78% of the IMA-patients and in 87% of the SVG-patients (NS). The mean loss of hemoglobin and total protein per 100 ml of shed blood was similar in IMA-, and SVG-patients with or without aprotinin, although aprotinin diminished the total amounts in both groups with 50% (p < 0.01).

[The waiting time for heart interventions: trends for percutaneous coronary interventions and cardiothoracic interventions]. / De wachttijd voor hartinterventie: trends voor angioplastiek en operatie.

OBJECTIVE: (a) To describe trends in the number of heart interventions performed over time, (b) to determine the length of waiting lists for elective heart interventions in the Netherlands according to the monthly survey of the Supervisory Committee for Heart Interventions in the Netherlands [Begeleidingscommissie Hartinterventies Nederland (BHN)], (c) to compare the length of the waiting lists with existing standards, and (d) to determine the reliability of the waiting list survey. DESIGN: Prospective. METHOD: Data were obtained from the monthly waiting list survey of the 13 heart centres in the Netherlands (1 January 1999-30 November 2002) and from the intervention registry (1 January 1999-30 June 2001), which was complete for 10 centres. Both the survey and the maintenance of the registry are carried out by the Supervisory Committee for Heart Interventions in the Netherlands. RESULTS: (a) The number of percutaneous coronary interventions performed in the Netherlands has increased. The number of cardiothoracic interventions remained stable. (b) The number of patients waiting for a percutaneous coronary intervention is increasing by 16% per annum. In November 2002 there were 751 patients on the waiting list. The number of patients waiting for a cardiothoracic intervention increased by 20% per annum until August 2001 and since then there has been a decrease of 21% per annum. In November 2002, 1557 patients were on the waiting list. (c) The percentage of patients treated within existing standards has fallen to 78% for percutaneous coronary interventions and to 53% for cardiothoracic interventions. (d) The length of the waiting list and the waiting times obtained in the survey concurred with the data taken from the intervention registry. CONCLUSIONS: The length of the waiting list for heart interventions has increased and complies increasingly less with existing standards. The monthly waiting-list survey was a reliable method of determining the length of waiting lists for elective heart interventions.

Clinical outcome of the PAS-Port® proximal anastomosis system in off-pump coronary artery bypass grafting in 201 patients.

AIM: The PAS-Port® Proximal Anastomosis System (Cardica, Inc, Redwood City, CA, USA) has been used worldwide since March 2003. The objective of the present study was to evaluate the clinical outcome of the PAS-Port® Proximal Anastomosis System. METHODS: All the patients who underwent off-pump coronary artery bypass grafting in the Catharina Hospital Eindhoven between August 2006 and April 2010 were included in a non-randomized retrospective case-control study, if they had at least one proximal vein graft anastomosis. Study end-points consisted of overall survival, coronary reintervention and postoperative stroke. RESULTS: The study included 312 patients (201 cases, 111 controls). After 36 months of follow-up there was no difference in survival between cases and controls (92.2% vs. 93.7%, P=0.52). No significant difference could be detected between cases and controls with respect to overall coronary reintervention-free survival (93% vs. 96.4%, P=0.20) and freedom from coronary reintervention due to proximal vein graft failure (98% vs. 100% P=0.14). The use of the PAS-Port system could not be identified as an independent risk factor of coronary reintervention (p=0.21). Postoperative stroke rates of cases and controls (2% vs. 0.9%, P=0.42) were comparable. CONCLUSION: The clinical outcomes in patients treated with the PAS-Port® Proximal Anastomosis System were satisfactory compared with those treated with the conventional hand-sewing technique. The use of the PAS-Port system was not associated with higher adverse outcome in terms of overall survival, stroke, coronary reintervention-free survival and freedom from reintervention due to proximal vein graft failure.

Inability to ventilate after tube exchange postoperative to pneumonectomy.

We report a case of inability to ventilate a patient after completion of pneumonectomy, due to migrated tumor tissue to the contralateral side. This represents an unusual complication with a high mortality rate. We have managed to find the cause in time and were able to remove the obstructive tissue using bronchoscopy.