Impact of a history of diabetes mellitus on quality of life after coronary artery bypass grafting

AIM: To describe the improvement in various aspects of quality of life (QoL) after coronary artery bypass grafting (CABG), in relation to a previous history of diabetes mellitus. PATIENTS: All patients from western Sweden who underwent CABG between 1988 and 1991 without simultaneous valve surgery. METHODS: Patients were approached with three questionnaires: The Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index prior to surgery and 3 months, 1 and 2 years thereafter. RESULTS: All three questionnaires already showed a significant improvement in QoL after 3 months, remaining at a similar level 1 and 2 years after the operation. In terms of Physical Activity Score improvement was of similar magnitude in diabetic and non-diabetic patients. In terms of the Psychological General Well-Being Index significant and similar improvements were found in diabetic and non-diabetic patients at each evaluation. In terms of the Nottingham Health Profile there was a significant improvement both in diabetic and non-diabetic patients 3 months, 1 and 2 years after the operation. However, improvement was more marked in diabetic than in non-diabetic patients at each evaluation. CONCLUSION: For 3 months, 1 and 2 years after CABG various aspects of QoL as estimated with three different instruments, improved significantly both in diabetic and in non-diabetic patients compared with the situation prior to the operation. However, the three instruments differed somewhat. Thus, whereas in the Physical Activity Score, diabetic patients tended to improve less markedly than non-diabetic patients, the opposite was found in the Nottingham Health Profile.     

Limitation of physical activity, dyspnea and chest pain prior to and during two years after coronary artery bypass grafting in relation to a history of hypertension

AIM: To describe the limitation of physical activity, the cause of limitation of physical activity and symptoms of dyspnea and chest pain before and 2 years after coronary artery bypass grafting (CABG) in relation to a history of hypertension. METHODS: All patients from western Sweden who underwent CABG between 1988 and 1991 were approached with a questionnaire--prior to, 3 months and 2 years after CABG--evaluating the issues raised above. RESULTS: Of 2121 patients, 37% had a history of hypertension. By 3 months after CABG, physical activity tolerance had improved markedly and in a similar way for both hypertensive (p<0.001) and non-hypertensive patients (p<0.001); this level was sustained for 2 years. Absence of dyspnea increased markedly and similarly among both hypertensive and non-hypertensive patients (p < 0.001) after CABG. The presence of chest pain decreased markedly and similarly among hypertensive (p<0.001) and non-hypertensive patients (p<0.001), both 3 months and 2 years after compared to prior to the operation. CONCLUSION: There was a marked improvement in terms of physical activity and cardiovascular symptoms 3 months and 2 years after CABG as compared with the situation prior to the operation. A previous history of hypertension did not seem to affect these results.     

The cost-benefit balance of coronary artery bypass grafting: need for hospitalization during the two years before and the two years after

To derive and compare the need for hospitalization during 2 years prior to coronary artery bypass grafting (CABG) and 2 years after, all the patients from western Sweden in whom CABG without simultaneous valve surgery was performed between June 1988 and June 1991 were evaluated. Hospitalization prior to and after surgery was derived via questionnaires sent to the patients and via data from their hospital medical record forms. In all, 2099 patients were studied. The mean total number of days in hospital was 16 during the 2 years before and 24 including surgery and postoperative complications during the 2 years after the operation (p < 0.001). When the days for operation and postoperative complications were excluded, the mean number of days after operation was 7 (p < 0.001). Hospitalization due to myocardial infarction, angina pectoris, percutaneous transluminal coronary angioplasty and other investigations for heart disease were significantly reduced after CABG. On the other hand, hospitalization due to chest pain with causes other than ischemic heart disease, congestive heart failure, arrhythmias, and reoperation was more frequent during the 2 years after surgery. The total number of days in hospital was higher during the 2 years after CABG than during the 2 years before, despite the fact that hospitalization due to ischemic events was significantly reduced after the operation.     

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: early and late results

AIM: To describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone. PATIENTS and METHODS: All patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988-1991. RESULTS: Among 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%). The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P < 0.0001 and P = 0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG. CONCLUSION: Among patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.     

Impact of coronary artery bypass grafting on various aspects of quality of life

OBJECTIVE: To prospectively study the improvement in quality of life (QoL) after coronary artery bypass surgery (CABG). PATIENTS AND METHODS: Consecutive patients (n = 2121) who underwent CABG at Sahlgrenska University Hospital between 1988 and 1991 received 3 questionnaires for the study of QoL: the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index, which were responded both before surgery and at 3 months (n = 1059), 1 year (n = 1045) and 2 years (n = 1027) postoperatively. RESULTS: All differences were tested against baseline. The Physical Activity Score improved (mean 4.3 before CABG, 3.1, 3 months after (P < 0.0001), and 2.8, 2 years postoperatively (P < 0.0001)). The Nottingham Health Profile score improved (mean 20.5 before CABG, 11.4, 3 months (P < 0.0001), and 10.4, 2 years postoperatively (P < 0.0001)). The Psychological General Well-being Index improved (mean 91.1 before CABG, 103.8, 3 months (P < 0.0001), and 105.8 (P < 0.0001), 2 years after CABG). The subscale analyses of the Nottingham Health Profile and the Psychological General Well-being Index 2 years after CABG showed the greatest improvement in areas reflecting physical capacity and pain, to be followed by mental qualities. At 2 years after CABG only sexual problems were still markedly frequent, and independent predictors for sexual problems after surgery were preoperative problems (P < 0.00001), male sex (P < 0.0001), and diabetes mellitus (P = 0.0008). CONCLUSION: QoL was markedly and significantly improved after CABG. The major improvement was seen already at 3 months, with further slight improvement observed 2 years after surgery. The major improvement was found in areas reflecting physical capacity and pain, which is consistent with symptomatic and objective measurements after CABG. In contrast to the overall improvement in QoL sexual problems were still markedly common 2 years after CABG. The mechanism for this is not fully understood and needs further investigation.     

Predictors of CABG within one year of successful PTCA: a retrospective, case-control study

BACKGROUND: We previously have established characteristics predictive of the need for coronary artery bypass grafting (CABG) over many years after successful percutaneous transluminal coronary angioplasty (PTCA). In this study, we examined the factors associated with the need for CABG within 1 year of successful PTCA, and the recent impact of newer, catheter-based technologies. METHODS: From January 1982 through December 1995, 234 patients underwent CABG within 1 year of a successful "index" PTCA at our hospital. Emergency operations within 12 hours of index PTCA were excluded. These cases were matched with 234 controls who underwent a successful index PTCA but did not require a subsequent CABG during the next year. Cases were matched by the date of their index PTCA, and 1-year follow-up was complete for all patients. RESULTS: Before index PTCA there were no differences between the groups in terms of age, sex, diabetes, prior myocardial infarction, ejection fraction, duration of anginal symptoms, hypertension, hyperlipidemia, family history, or obesity (all nonsignificant). At index PTCA the cases had a greater mean number of lesions measuring 70% or greater compared with the controls (2.8 versus 1.8, respectively; p < 0.0001). The cases were more likely to have critical (70% or greater) proximal left anterior descending artery, proximal first obtuse marginal artery, and right posterior descending artery stenoses. The use of stents or atherectomy devices was not significantly more common among the controls (21% of controls versus 17.1% of cases; p = 0.35). Complete revascularization was achieved in significantly fewer of the cases than the controls (91 versus 156, respectively; p < 0.0001). The cases underwent CABG at a mean of 3 months (86% within 6 months) after PTCA. Among those who had a diagnostic catheterization, 52% of the patients had both restenosis of a dilated lesion and progression of other disease. Only 5 of 75 patients who had restenosis of a dilated lesion had a stent or an atherectomy device used at index PTCA. Of note, 13% (30 of 234) required an emergency operation, with an overall operative mortality rate of 3% (7 of 234). CONCLUSIONS: Although the likelihood of local restenosis is decreased by newer interventional techniques, the need for CABG within 1 year after successful PTCA is not diminished. The number of critical lesions and their location are the best predictors of the need for early CABG. If early post-PTCA CABG is to be avoided, patients who cannot be completely revascularized by PTCA should be revascularized by CABG.     

The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit]

BACKGROUND: The appropriate timing of elective coronary artery bypass surgery (CABG) following acute myocardial infarction (AMI) remains uncertain. It is hypothesized that a waiting period allows the myocardium to recover prior to revascularization, thus decreasing morbidity and mortality. This study was designed to determine if a waiting strategy is justified following AMI in patients requiring elective CABG. METHODS: Between 1994 and 1996, 214 patients underwent isolated, nonrepeat, elective CABG. Three groups were evaluated: group I, control, 155 patients with no AMI; group 11, 39 patients with nontransmural AMI; and Group III, 20 patients with transmural AMI. Demographics, intraoperative, and postoperative variables were collected and compared among all groups. RESULTS: Groups were well-matched demographically: group I, patients waited an average of 2.3 days in hospital prior to operation; group II, an average of 4.2 days; and group III, an average of 5.2 days. Except for the use of inotropes, group I 34%, group 11 39%, and group III 70% (P = 0.007), and the intra-aortic balloon pump, group I 0%, group 11 8%, and group III 25% (P = 0.001). There were no differences in complications. Importantly, there was no difference in mortality or postoperative length of stay. The mortality in group I was 2.6%, in group 11 2.6%, and in group III 0%. The length of stay in groups I and II was 8.5 days, and in group III, 8.1 days. CONCLUSION: A waiting period of 3 to 5 days after a nontransmural AMI and 5 to 7 days after a transmural AMI can produce similar postoperative results to non-AMI patients undergoing CABG. Thus, a waiting strategy to allow the myocardium to recover is justified.     

1997 Paul Ehrlich and Ludwig Darmstaedter Prize for the rediscovery of Helicobacter pylori to J. Robin Warren and Barry J. Marshall

The aim of this study was to: (i) test different instruments that focused on sleep, quality of life and personal adjustment in order to evaluate the usefulness of these instruments in a larger study; and (ii) to describe self perceptions of sleep and life situation by patients who had undergone coronary artery bypass grafting (CABG). A one-group pre-test repeated post-test design was used. Six men aged between 51 and 70 years were interviewed, and 24 h polysomnographic recordings were performed before and after the operation. The interviews indicated disturbed sleep and changes in behaviour and mental state immediately postoperatively. Postoperatively the polysomnographic recordings revealed a significant decrease in mean duration of sleep, mean percentage of stage 3-4 sleep and mean rapid eye movement (REM) sleep. One month after surgery the quality of life was improved, while moderate anxiety and sensation of incisional pain persisted. The measurements used in this pilot study provide valuable information into the understanding of altered sleep, quality of life and personal adjustment following CABG.     

Quality of life and dementia

OBJECTIVE: To review the relationship between quality of life (QOL) and dementia. Development. QOL is a factor which takes into account all the different aspects of life which make a person feel that life is worth living, such as: 1. Physical health. 2. Functional status. 3. Psychological and cognitive sphere, and 4. Social health. There are two types of instruments for evaluating these aspects: firstly general ones which measure the QOL independently of illness, and secondly those which are specific to the illness concerned. In dementia, QOL covers the same traditional areas: cognitive competence, capacity to carry out everyday activities, social conduct and the balance between positive and negative emotions. However, evaluation of QOL in dementia has its own specific difficulties, since it is often impossible to determine such a fundamental factor as the subjective well-being of the patient, in which case the opinion of the person looking after the patient is essential. According to Lawton's approximation, as well as the subjective aspect of perceived psychic welfare and quality of life, the QOL in dementia is composed of external social and objective dimensions such as behaviorally competence and the quality of the patient's environment. In a review done in 1995 it was found that most of the instruments designed to measure the QOL have not been sufficiently validated for Alzheimer's disease. CONCLUSIONS: QOL in dementia has specific features including external aspects such as the opinion of the carer and the quality of the patient's environment in addition to the subjective aspects. It is necessary to develop and validate specific instruments for QOL in dementia.     

Kinetic diversity in the fusion of exocytotic vesicles

Age is the most important factor for the durability of biological valves. With an original design the Carpentier-Edwards pericardial valve showed improved results at 10 years. The influence of age on valve related complications is studied with a 10 year follow up on 807 valvular replacements. METHODS: Between January 1984 and December 1993, 807 patients underwent valve replacements with a Carpentier-Edwards pericardial bioprosthesis. Patients, 193 were younger than 60 years, 284 between 60 and 70 years and 330 patients were older than 70 years. All patients but seven were followed up for an average of 4.18 years after their operation and total follow up was 3373 patient years. Patients were divided into three groups of age: group I, less than 60 years; group II, 60-70 years; group III, over 70 years. A retrospective comparison was made between age groups. RESULTS: At 11 years, valve related complications included 97 patients with 27 valve related deaths. Rates of valve related death increase with age linearized rate were 0.3, 0.6 and 1.2%, respectively. No difference was observed for rates of all valve related morbidity: 2.6, 2.4 and 3.5%, respectively. Risk of thromboembolism increased with age, linearized rates were: 0.3, 0.7 and 1.3%. Risk of deterioration and reoperation decreased with age, rates of deterioration were 0.8, 0.1 and 0%. Other valve related events had the same incidence in all groups. No statistical difference was observed between group II and group III for deteriorations and reoperations. CONCLUSIONS: The performance of the Carpentier-Edwards pericardial valve is the same at 10 years in group II and III. This study supports the clinical use of this tissue valve in patients over 60 years. The results in group I are satisfactory, nevertheless, a more durable biological valve is needed for young patients.     

Mid-term results in coronary revascularization using the right gastroepiploic artery graft

We studied the mid-term results in 191 patients (including emergent operation in 27 patients) who have performed coronary artery bypass grafting (CABG) using the right gastroepiploic artery (REGA) for 74 months (mean follow up period was 37 months). We evaluated the postoperative results in terms of 1. mortality and survival rate, 2. graft angiography, 3. cardiac event free rate and 4. abdominal complications. We had operative death in 6 patients (3.1%) including 3 patients of emergent operations. Late deaths were found in 11 patients (5.9%): 2 patients were cardiac death and 9 were non-cardiac. The actual survival rates were 94.2% at one year, 90.0% at three years and 85.9% at five years. Early patency rate of the RGEA was 98.9% (n = 178). However flow competition between the RGEA and native coronary artery was seen in 42 patients (24.0%). Mid-term patency rate was 96.4% (n = 28). According to mid-term graft angiography, 1 patient improved and 5 patients got worse in comparison with early control. Cardiac event free rates were 98.2% at 1 year, 94.8% at 3 years and 92.7% at 5 years. Abdominal complications were observed in 5 patients (1 patient of bleeding from the RGEA, 1 of gastric perforation, 2 of bleeding from gastric ulcer and 1 of pyloric stenosis) at early period and in 7 patients (2 patients of incisional hernia and 5 of gastric cancer) at long-term period. Early and mid-term results of CABG using the RGEA were quite good. However, the RGEA had a tendency of flow competition against native coronary artery and a problem of gastric cancer after the operation.     

Open-heart surgery in a growing geriatric population: patient selection and risk factors to be considered

AIMS: This report describes our experience with cardiac surgery in elderly patients and aims to ascertain predictors of poor outcome. PATIENTS: Five hundred and ninety-eight (598) consecutive patients aged 75 years and older underwent cardiac surgery at the Department of Cardiothoracic Surgery, University Hospital of Lund, Sweden, between January 1980 and December 1993. There were 324 men (54%) and 274 women (46%); their age varied between 75 and 91 years (mean age +/- SD, 77.8 +/- 2.6 years). One hundred and twenty-nine patients underwent aortic, mitral or combined valve replacement, 273 patients underwent exclusive coronary revascularization (CABG) alone and 109 underwent a surgical procedure which included valve replacement and concomitant CABG. The remainder (87 patients) underwent other, more complex surgical procedures. RESULTS: The 30-day or in-hospital mortality rate was 5.5% (0.8% for valve replacement, 5.1% for CABG, 5.5% for valve replacement with concomitant CABG, and 12.6% for other procedures). Concomitant severe diseases occurred in 34.9% of the patients. All surviving patients were evaluated during June 1994. None of the patients was lost to follow-up. The 566 long-term survivors have been followed for an average of 23.0 months (median 21; range 1-53 months). Late mortality was 12.0% in the 566 hospital survivors. Only 17 patients experienced late complications (after hospital discharge), as an adverse effect linked to heart surgery.     

Comparative effect of tranexamic acid on the reduction of bleeding during and after cardiac surgery

The administration of tranexamic acid (TA), an antifibrinolytic agent, prior to cardiopulmonary bypass (CPB) has been reported to reduce bleeding after cardiac surgery. In a retrospective clinical trial, 99 adults patients undergoing open heart surgery received TA (CABG, TA (+): n = 20; Valve replacement, TA (+): n = 20) or did not receive TA (CABG, TA (-): n = 20: Valve replacement, TA (-): n = 19). In the TA group, just after induction of general anesthesia, a 160 mg.kg-1 dose of TA was administered intravenously. In each group, bleeding volumes during operation, and at 6 and 24 hours after operation, were compared. Patients of [CABG, TA (+)] group had significantly less intraoperative and total blood loss [total blood loss 608 g : 313 g, intraoperatively, 134 g at 6 hours, and 296 g at 24 hours] compared with [CABG, TA (-)] group (total blood loss 1043 g: 640 g, intraoperatively, 232 g at 6 hours, and 403 g at 24 hours). Additionally, in patients of Valve replacement, TA (+) group had less but not significant total blood loss (total blood loss 903 g: 523 g, intraoperatively, 173 g at 6 hours, and 380 g at 24 hours) compared with TA (-) group (total blood loss 1237 g: 863 g, intraoperatively, 214 g at 6 hours, and 374 g at 24 hours). TA administered prior to CPB may reduce the amount of bleeding during and after cardiac surgery.     

Paternal uniparental disomy for chromosome 1 revealed by molecular analysis of a patient with pycnodysostosis

OBJECTIVES: We sought to determine the prognostic capabilities of exercise thallium (Tl)-201 tomographic imaging performed relatively early (within 2 years) after coronary artery bypass graft surgery (CABG). BACKGROUND: Exercise testing is commonly performed after CABG, but few data exist demonstrating its prognostic value in this setting. METHODS: Four hundred eleven patients were followed up for a median duration of 5.8 years. Eleven prospectively chosen clinical, exercise and Tl-201 variables were tested for their associations with outcome end points by means of proportional hazards regression models. RESULTS: During follow-up there were 60 deaths from any cause, 53 initial cardiac deaths or nonfatal myocardial infarctions (MIs) and 22 late (>3 months after the Tl-201 study) revascularization procedures. The number of abnormal Tl-201 segments on the postexercise image was the only variable in the multivariate analyses to show a significant association with all three outcome end points: chi-square 7.3, p = 0.007 for overall mortality; chi-square 8.1, p = 0.004 for cardiac death or MI; chi-square 7.8, p = 0.005 for any cardiac event. Other independent predictors of outcome were exercise duration (chi-square 10.7, p = 0.001) and age (chi-square 3.9, p = 0.049) for overall mortality and exercise angina score (chi-square 8.7, p = 0.003) for cardiac death or MI. The 5-year survival rate free of cardiac death or MI was 93% for patients without angina and a normal image or small postexercise perfusion defect versus 71% for patients with angina and a medium or large defect. CONCLUSIONS: Exercise Tl-201 imaging performed within 2 years of CABG can stratify patients into low and high risk subgroups.     

Hereditary persistence of alpha-fetoprotein. Case report and review of the literature

BACKGROUND: The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. METHODS: Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n = 10), benign disease (n = 2) and carcinoid (n = 1). Lung resections included pneumonectomy (n = 3), lobectomy (n = 4), segmentectomy (n = 1) and local excision (n = 5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. RESULTS: There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n = 3), anticoagulant related haemorrhage (n = 1) and broncho-pleural fistula (n = 1). Of the remaining five patients four are alive and disease free 7-23 months post-operatively; one patient has recurrent disease 40 months post-operatively. CONCLUSIONS: Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.     

Results of laparoscopic Nissen fundoplication

BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations. METHODOLOGY: Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation. RESULTS: Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%). CONCLUSIONS: The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

Randomized comparison of four tools measuring overall quality of life in patients with advanced cancer

PURPOSE: We report on a clinical trial developed to compare four different instruments that provide overall quality-of-life (QOL) scores, ranging from a simple, one-item instrument to more detailed instruments. Two issues addressed were (1) Will QOL tools suffer from missing data when used in a community-based cooperative group setting?, and (2) Are there additional data generated by a more detailed multiitem instrument over that provided by a single-item global QOL question? MATERIALS AND METHODS: A four-arm randomized trial was designed to compare four instruments that provide overall QOL scores in patients with advanced colorectal cancer. Patients and physicians completed the single-item Spitzer Uniscale (UNISCALE) at baseline and monthly. Patients were randomly assigned to complete, in addition, either the 22-item Functional Living Index-Cancer (FLIC), the five-item Spitzer QOL index (QLI), a picture-face scale (PICT), or nothing else. RESULTS: A total of 128 patients were randomized. Greater than 90% complete QOL data were obtained. There was strong correlation, concordance, and criterion-related validity among all four patient-completed tools. The UNISCALE had a greater decrease over time than did the FLIC (P=.005), which suggests a greater sensitivity; the UNISCALE was similar to the QLI and the PICT in this regard. Physicians provided lower UNISCALE scores than patients. Results supported the hypothesis that QOL is prognostic for survival. CONCLUSION: Patients can effectively complete QOL tools in a cooperative group setting with proper education of health care providers and patients. A simple single-item tool (UNISCALE) appears to be appropriate to obtain a measure of overall QOL.     

Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease

BACKGROUND: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease. METHODS: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group. RESULTS: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62). CONCLUSIONS: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.     

Early assessment of viable myocardium after acute myocardial infarction by low-dose echo-dobutamine

BACKGROUND: The aim of the study was to evaluate the usefulness of low-dose dobutamine echocardiographic testing performed within 48 hours from anterior AMI in order to identify the extent of viable myocardium and predict its functional outcome. The early echo-dobutamine test was also compared with a predischarge test in order to evaluate the effects of different timing on the accuracy of the test. METHODS: Nineteen consecutive patients, aged 54 +/- 11 years, with a first anterior AMI entered the study. All patients underwent a low-dose dobutamine echocardiographic test within 48 hours from hospital admission and at predischarge. In all the patients, a rest follow-up echocardiogram was performed three months after hospital discharge. Eleven patients underwent a revascularization procedure (7 underwent PTCA and 4 CABG). RESULTS: Of the 159 dyssynergic segments, 26% improved spontaneously at predischarge and 51% improved at the three-month follow-up. Of the 145 predischarge dyssynergic segments, 38% improved at three months. Considering the results on a segmental basis, early low-dose dobutamine echocardiography showed a sensitivity of 52%, a specificity of 87%, a positive predictive value of 81%, a negative predictive value of 64% and a diagnostic accuracy of 69% for wall-motion improvement at three months. The predischarge test showed very similar values. A slight enhancement of the sensitivity of both tests was observed considering the akinetic segments only. Finally, considering the amount of segmental reversible dysfunction inside the infarct area in the single patients, early low-dose dobutamine echocardiography showed a sensitivity of 86% and a specificity of 80%. CONCLUSIONS: Our results indicate that: 1) recovery of regional wall motion after AMI is slow and progressive, with substantial improvement ensuing within the first days after infarction; 2) considering results on a segmental basis, low-dose dobutamine echocardiography performed within 48 hours of AMI shows a high specificity but a low sensitivity for late recovery of regional function, although it gave information similar to what was obtained performing the test at predischarge; 3) the efficiency of test can be improved by considering the amount of reversible segmental dysfunction inside the infarct area in the single patients.