Coronary artery bypass grafting without cardiopulmonary bypass

In off-pump coronary artery grafting, cardiopulmonary bypass and its associated maneuvers, i.e., aortic manipulation and global cardiac arrest, may be avoided, and thus its morbidity and mortality may be reduced. Modern tissue stabilizers allow accurate construction of anastomosis and are now considered indispensable. Currently, there are two groups of stabilizers, i.e., those based on suction-fixation and those based on pressure-fixation. Each has specific applications. The popularity of off-pump coronary bypass surgery is increasing, from the patient's perspective and from the perspective of cost containment. Proper patient selection is crucial. The procedure is technically demanding. It is expected that by the year 2000 10% of coronary surgery will be off-pump, particularly by direct vision techniques. From the currently available, nonrandomized, prospective studies, the preliminary conclusion seems justified that, in selected patients, off-pump bypass grafting is as accurate as conventional bypass grafting, with lower morbidity and mortality. This includes fast recovery and early resumption of premorbid activities in most patients. Particularly, therefore, the procedure is also cost saving. Prospective randomized studies are necessary to quantify these statements.     

Coronary artery bypass grafting in patients with cerebrovascular disease

The incidence of carotid artery disease in patients undergoing coronary artery bypass grafting appears to be increasing as our population ages. The optimal treatment for these high-risk patients with concomitant carotid and coronary artery disease remains controversial. This review focuses on the management of patients with coexistent carotid and coronary arteriosclerosis. The significance and management of the patient with an asymptomatic carotid stenosis in patients undergoing coronary artery bypass grafting and the role of combined coronary artery bypass grafting and carotid endarterectomy in these patients will be discussed.     

Coronary artery bypass grafting in cases with poor left ventricular function

From January 1987 through June 1992, 18 patients with poor left ventricular function (left ventricular ejection fraction [LVEF] less than 0.3) underwent elective isolated primary coronary artery bypass surgery. The mean age was 56.4 years (range, 46 to 72 years), and 15 were males and 3 were females. Mean pre-operative LVEF measured by ventriculography was 0.26 +/- 0.03 (range, 0.19 to 0.30). Sixteen patients (88.9%) had a prior myocardial infarction and 9 (50%) had a history of congestive heart failure. Complete revascularization was the goal for all patients, and the mean number of bypass grafts was 3.0 +/- 0.8 per patient. The left anterior descending coronary artery (LAD) was revascularized in all patients. There were no operative deaths. Post-operative LVEF improved significantly from 0.26 +/- 0.03 to 0.42 +/- 0.11 (p = 0.0002), and the regional left ventricular wall motion improved in the diaphragmatic and posterobasal regions (p < 0.01). The patency of the grafts was 93.9% in all, and 100% for LAD. The mean follow-up period was 77 months, and the overall actuarial survival rate was 88.9% at 10 years. During follow-up periods, two patients died of congestive heart failure (CHF), and two required three rehospitalizations because of CHF. The overall cardiac event free rate was 75.8% at 10 years. In patients with poor left ventricular function, surgical revascularization can be performed safely, but congestive heart failure sometimes occurs during follow-up periods and may be the cause of death. Therefore alternate forms of therapy such as cardiac transplantation and/or TMLR should be considered in selected patients.     

Combination chemotherapy in refractory immune thrombocytopenic purpura

BACKGROUND: Chronic idiopathic thrombocytopenic purpura is a destructive thrombocytopenia caused by an autoantibody. About 80 percent of patients with chronic idiopathic thrombocytopenic purpura have remissions after either corticosteroid therapy or splenectomy. Some patients with resistant disease respond to other agents, but a substantial group are refractory to therapy. METHODS: We used combination chemotherapy to treat 10 patients with refractory immune thrombocytopenia. An average of 6.8 (range, 3 to 10) previous therapies, including corticosteroids and splenectomy, had been unsuccessful in these patients. The patients received from three to eight cycles of therapy consisting of cyclophosphamide and prednisone combined with either vincristine (one patient), vincristine and procarbazine (four patients), or etoposide (six patients, including one patient who received four cycles each containing procarbazine and etoposide). RESULTS: Among the 10 patients, 6 had complete responses (platelet count, > 180,000 per cubic millimeter); of these, 4 patients had responses that persisted for more than 11, 30, 54, or 126 months, 1 had a relapse 9 months after therapy but had a remission with further therapy and remained in remission for 48 months before dying of an unrelated illness, and another relapsed just before her fifth course of therapy. Two patients had partial responses (platelet count, > 50,000 per cubic millimeter); the platelet counts in one remained stable for more than nine months after the end of therapy, and the other patient relapsed. The remaining two patients had no response. Complete responses were associated with a disappearance or marked decrease in the level of platelet-associated autoantibody. CONCLUSIONS: Combination chemotherapy is beneficial in some patients in whom immune thrombocytopenia is refractory to corticosteroids and splenectomy.     

Laparoscopic splenectomy for immune thrombocytopenic purpura

A very unusual case of traumatic tricuspid regurgitation is reported, with severe symptoms of right ventricular failure, extreme dilatation of the right heart, echocardiographic and angiographic criteria of major tricuspid regurgitation, and severe right ventricular systolic dysfunction. The patient was referred for heart transplantation, on the assumption that conventional surgery was not possible. After careful evaluation, as the patient had normal pulmonary artery pressure and resistance, a tricuspid valve was replaced with good surgical outcome.     

Coronary artery bypass grafting under the beating heart in a patient with insufficient cardiopulmonary bypass

Coronary artery bypass grafting in a 64-year-old male with a severe calcified ascending aorta was performed under the beating heart, because of insufficient cardiopulmonary bypass. The patient suffered inferior and anterolateral myocardial infarction with moderate mitral regurgitation. Computerized tomography showed a severely calcified ascending aorta. During the operation, cardiopulmonary bypass was conducted with femoral arterial cannulation and bicaval cannulation. Adequate perfusion flow, however, could not be achieved. Anastomoses of left internal thoracic artery-left anterior descending artery and right gastroepiploic artery-right coronary artery were performed under a beating heart supported by cardiopulmonary bypass. The patient made an uneventful recovery and postoperative angiography revealed patent grafts. Mitral regurgitation remained unchanged, but the postoperative lifestyle has been stable for the last 15 months.     

Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery

OBJECTIVES: We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). BACKGROUND: Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. METHODS: We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). RESULTS: Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group. CONCLUSIONS: In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.     

Coronary artery bypass grafting performed by the simple and convenient graft supporter

We have experienced a simple, safe and convenient technique for supporting the arterial or saphenous vein graft in the coronary artery bypass grafting. This graft supporter is made of cotton cloth with a 50 percent polyester mix. The supporter is twenty centimeters long and two centimeters wide. This supporter provides the complete fixation of the graft without the holding by the co-operater. Therefore the supporter allows very easy, safe and accurate graft anastomosis with the native coronary artery or the ascendinbg aorta. No complication was encountered in association with this procedure in 127 operations.     

Repeat coronary artery bypass grafting

Repeat coronary bypass grafting was performed in 19 patients. The mean age was 59.8 +/- 6.9 years, 26% being female. One or more coronary risk factors were observed in 10 to 37% and none in 37%. The mean interval from the initial procedure was 35.6 +/- 34.4 months, but 42% of patients were reoperated within one year. Eleven patients had unstable angina two requiring emergency surgery to achieve hemodynamic stabilization. A mean of 2.63 grafts/patient achieved 87.7% revascularization. Two patients died late postoperatively from surgical complications. Sixteen patients consented to have postoperative coronary angiography: IMA was used as conduit in one third of the grafts and had a patency of 100% (15/15), compared to 86.7% of the venous grafts (26/30), for an overall patency of 91%. Follow up for 1 to 65 months (28.2 +/- 20.1 months) showed that 75% (12/16) are asymptomatic, and 4 patients (25%) have mild angina (NYHA II). Three of these 4 patients with recurrent angina have evidence of incomplete revascularization. Thus, repeat coronary bypass operation can be offered with acceptably low risk, and the long term benefits are similar to those obtained with primary operation providing complete revascularization is achieved, preferably with multiple internal mammary artery grafting techniques.     

Laparoscopic versus open splenectomy for immune thrombocytopenic purpura

Erythrokeratodermia variabilis (EKV, OMIM 133200) is an autosomal dominant genodermatosis with considerable intra- and interfamilial variability. It has a disfiguring phenotype characterized by the independent occurrence of two morphologic features: transient figurate red patches and localized or generalized hyperkeratosis. Both features can be triggered by external factors such as trauma to the skin. After initial linkage to the RH locus on 1p, EKV was mapped to an interval of 2.6 cM on 1p34-p35, and a candidate gene (GJA4) encoding the gap junction protein alpha-4 (connexin 31, Cx31) was excluded by sequence analysis. Evidence in mouse suggesting that the EKV region harbours a cluster of epidermally expressed connexin genes led us to characterize the human homologues of GJB3 (encoding Cx31) and GJB5 (encoding Cx31.1). GJB3, GJB5 and GJA4 were localized to a 1.1-Mb YAC in the candidate interval. We detected heterozygous missense mutations in GJB3 in four EKV families leading to substitution of a conserved glycine by charged residues (G12R and G12D), or change of a cysteine (C86S). These mutations are predicted to interfere with normal Cx31 structure and function, possibly due to a dominant inhibitory effect. Our results implicate Cx31 in the pathogenesis of EKV, and provide evidence that intercellular communication mediated by Cx31 is crucial for epidermal differentiation and response to external factors.     

Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass

To determine the feasibility and the effectiveness of minimally invasive direct coronary artery bypass without cardiopulmonary bypass (MICABG) in patients with left anterior descending (LAD) coronary artery disease, we evaluated 90 consecutive patients who underwent MICABG at the University Hospital of Groningen. PATIENTS: Between January 1995 and December 1996, 50 patients (mean age 60 +/- 10.3 years) with documented myocardial ischemia and isolated stenosis of the LAD were selected for MICABG. Patients with any associated cardiac disease or with acute or evolving myocardial infarction were excluded. METHODS: A small left antero-lateral thoracotomy in the 5th intercostal space was made in all patients, anastomosing the left internal mammary artery (LIMA) to the LAD. A short-term (3 days) postoperative rehabilitation programme was used. Emotional stress (STAY-DY-1 score), wound pain (VAS: visual analogue score) and O2-saturation after a 6 min walking test were measured during hospitalisation and at the first follow-up examination (2.5 week after discharge). RESULTS: Mean operative time was 92 +/- 25 min (range 60-170). We recorded 1 (1.1%) in-hospital death and three cases (3.3%) of perioperative myocardial infarction. In two cases the MICABG was converted to the midline sternotomy. One patient underwent urgent reoperation on postoperative day 1 via midline sternotomy. Mean hospital stay was 4.4 +/- 2 days. Emotional stress was significantly reduced during and after hospitalisation, compared with the admission day. Wound pain was mild (3.5/10 VAS) on postoperative day 1 and reduced significantly during hospitalisation and at first follow-up examination. O2-saturation after a 6 min walking test had significantly improved at the first follow-up examination. CONCLUSION: These results indicate that MICABG is feasible and effective in patients with LAD stenosis and leads to a fast psycho-physical recovery.     

Effect of aspirin in coronary artery bypass grafting

OBJECTIVES: To evaluate the effect of aspirin (ASA) therapy on postoperative blood loss, transfusion requirements, reoperation for bleeding, duration of stay in the intensive care unit and in the hospital in a selected population undergoing a first coronary artery bypass grafting (CABG) surgery. DESIGN: Prospective observational study in consecutive patients during a 3-month period. SETTING: A teaching cardiothoracic center. PARTICIPANTS: Two hundred forty consecutive patients undergoing elective coronary artery bypass grafting surgery for the first time. INTERVENTIONS: Two hundred forty consecutive patients admitted for a first CABG the day before surgery were visited. patients with an abnormal routine coagulation screen or taking drugs that might have affected their coagulation mechanisms were prospectively excluded (n = 96). The date of the last dose of ASA was recorded in the 144 remaining patients, and data were acquired prospectively. MEASUREMENTS AND MAIN RESULTS: Total mediastinal blood drainage, blood products usage, reopening, and duration of intensive care unit and hospital stay were recorded. Patients were grouped by days free of ASA. There were no significant differences detected between groups. CONCLUSIONS: In patients undergoing a first CABG and with no known factors affecting their coagulation, ASA therapy did not appear to increase blood loss, reopening for bleeding, or blood products usage requirements during the hospital stay. ASA therapy did not influence the duration of stay in intensive care or in the hospital.     

Internal thoracic artery holder for coronary artery bypass grafting

An arterial graft holder was designed to facilitate coronary artery bypass grafting using arterial conduits. It is possible to open the heel of the arterial conduit and stitch the most difficult angle of the anastomosis under optimal visualization. This internal thoracic artery holder is atraumatic and protects the arterial conduit wall from crush injuries caused by vascular forceps. Anastomosis without the endothelial injury may provide long-term patency of the coronary artery bypass graft.     

Minimally-invasive, direct coronary artery bypass grafting

BACKGROUND: Minimally-invasive, direct vision coronary artery bypass grafting (MIDCAB) is a new surgical technique performed via limited thoracotomy in a beating heart without cardiopulmonary bypass. METHODS: From June 1996 to December 1996, MIDCAB was performed in 12 patients (all male, average age, 65.9 years). In 11 patients with left anterior descending coronary artery lesions, thoracotomy was performed via the left, fourth intercostal space and the pericardium was incised to identify the target site. About 8 cm of the left internal mammary artery was harvested. Bilateral anterolateral thoractomy was performed in one patient with left anterior descending and right coronary artery lesions. Anastomosis was performed under direct vision in the beating heart without cardiopulmonary bypass. RESULTS: MIDCAB was performed successfully without morbidity. The patients' average stay in the intensive care unit was 1.8 days. No patient had any early cardiac event requiring additional surgery or percutaneous transluminal coronary angioplasty. Postoperatively, all patients were asymptomatic and their recovery was uneventful. CONCLUSIONS: Our initial experience indicates that MIDCAB offers good results and is a treatment option for selected patients with left anterior descending and/or right coronary artery lesions.     

Coronary artery bypass surgery during pregnancy

A 32-year-old woman, in the 22nd week of pregnancy, underwent emergency coronary artery bypass grafting to the left anterior descending artery (LAD). She had suffered an acute myocardial infarction 10 days previously, and continued to suffer from intractable angina pectoris afterwards. Cardiac catheterization revealed spontaneous dissection of the LAD. The left internal mammary artery was used to bypass the LAD, and the operation was performed on a beating heart without the use of cardiopulmonary bypass. The patient's recovery was uneventful, and ultrasound examination and pulse monitoring of the fetus were both normal. She subsequently gave birth to a healthy term baby. To our knowledge this is the second report of coronary artery bypass surgery performed successfully in a pregnant woman. We believe the unique surgical approach avoided the risk of cardiopulmonary bypass to the fetus and placenta.