Five-Year Outcome After Off-Pump or On-Pump Coronary Artery Bypass Grafting in Elderly Patients.

BACKGROUND: The 30-day and 1-year follow-up analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients) revealed no significant difference in the composite end point consisting of death, stroke, myocardial infarction, new renal replacement therapy, or repeat revascularization. The 5-year follow-up data of this trial are reported here. METHODS: From June 2008 to September 2011, a total of 2539 patients aged ≥75 years were randomly assigned to undergo off-pump or on-pump coronary artery bypass grafting (CABG) at 12 centers in Germany. The primary outcome was all-cause mortality at 5 years. The secondary 5-year outcomes were a composite of death, myocardial infarction, and repeat revascularization. Furthermore, the impact of complete versus incomplete revascularization was assessed. RESULTS: After a median follow-up of 5 years, 361 patients (31%) assigned to off-pump CABG and 352 patients (30%) assigned to on-pump CABG had died (hazard ratio off-pump/on-pump CABG, 1.03; 95% CI, 0.89-1.19; P=0.71). The composite outcome of death, myocardial infarction, and repeat revascularization occurred in 397 (34%) after off-pump and in 389 (33%) after on-pump CABG (hazard ratio, 1.03; 95% CI, 0.89-1.18; P=0.704). Incomplete revascularization occurred in 403 (34%) patients randomly assigned to off-pump and 354 (29%) patients randomly assigned to on-pump CABG ( P<0.001). Five-year survival rates were 72% (95% CI, 67-76) with incomplete versus 76% (95% CI, 74-80) with complete revascularization (log-rank test: P=0.02) after off-pump CABG and 72% (95% CI, 67-76) versus 77% (95% CI, 74-80) after on-pump CABG (log-rank test: P=0.03), respectively. Cox regression analysis revealed a hazard ratio incomplete/complete revascularization of 1.19 (95% CI, 1.01-1.39; P=0.04). CONCLUSIONS: In elderly patients ≥75 years of age, the 5-year survival rates and the combined outcome of death, myocardial infarction, and repeat revascularization, as well, were similar after on-pump and off-pump CABG. Incomplete revascularization was associated with a lower 5-year survival rate, irrespective of the type of surgery. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00719667.

[Case of a young woman successfully operated on for acute pulmonary embolism and right ventricular thrombus after urogenital infection]. / Akut tüdoembolia és jobb kamrai thrombus sikeresen operált esete fiatal nobeteg urogenitalis infekciója után.

The authors report a case of a 22-year-old women operated on for pulmonary embolism with success. The venous embolism developed in two phases one week apart. The first clinical sign was a dyspnea of abrupt onset limiting physical activity even after a mild exertion. However, relevant diagnostic tests were performed after one week when the patient fainted, her dyspnea worsened. The results of ECG, echocardiography and pulmonary perfusion scintigraphy indicated the presence of a thrombus residing in the right ventricle and the embolism of the right pulmonary artery. Chest CT and pneumo-angiography findings show the embolus completely blocking the main right branch of the pulmonary artery and partially blocking the left lower lobe artery. On the basis of their experiences published earlier the patient was brought to a stable cardio-respiratory state prior to surgery. Both the adherent right ventricular thrombus and the fresh embolus residing in the right branch of the pulmonary artery were removed under the protection of extracorporeal circulation. After the elapse of an event-free 6-month postoperative period the patient continued to remain symptomless, while being on a long-term anticoagulant regimen. The long-term anticoncipient medication and the urogenital infection 3 months prior to surgery may have been involved in the etiology of the pulmonary embolism. The authors propose the implementation of an antithrombotic prophylaxis in young women after gynecological infections.

[The advantages of axillary artery cannulation in surgical treatment of type A acute aortic dissection]. / Az arteria axillaris kanülálás elonyei az akut "A" típusú aorta dissectio sebészi kezelésében.

There are more alternative cannulation techniques during surgery of type A aortic dissection. The most frequently used femoro-atrial cannulation method provides limited possibility for brain protection during surgery. This theory is confirmed by relatively high frequency of major brain complications in patients operated on while using this cannulation technique. During the last years cannulationis used more often, as it may provide more protection for the brain than other methods. In 2003 seven patients underwent aortic reconstruction because of type A acute aortic dissection using axillary cannulation. All patients except one were discharged after uneventful recovery. There were no postoperative neurological complications following surgery. We lost one patient due to distal progression of the dissection. He was the only patient with clinical evidence of transient postoperative brain damage. We are strongly convinced that the spectacular improvement in our results for the surgery of type A acute aortic dissection is due to the axillary cannulation, the anterograde flow and the isolated cerebral perfusion. We recommend the axillary cannulation technique as the first choice in type A acute aortic dissection.

Magnetic resonance imaging-based biventricular pacemaker upgrade.

This report describes a patient with drug refractory severe chronic ischemic heart failure, atrial fibrillation with bradycardia, and left bundle branch block who had a failed implantation of a biventricular pacemaker because of a high left ventricular pacing threshold. VVI pacemaker implantation had not improved the patient's condition. MRI-guided biventricular pacemaker upgrade had been performed with a left ventricular epicardial lead at the lateral region where a 4-mm thickening during systole had been proven. After 6 months of effective resynchronization, the patient's functional class improved to NYHA II without further need of hospitalization.