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.     

Improvement in quality of life during 5 years after coronary artery bypass grafting

OBJECTIVE: To describe the changes in various aspects of quality of life (QOL) from before coronary artery bypass grafting (CABG) to 5 years after the procedure. PATIENTS AND METHODS: Patients who underwent CABG in the western region of Sweden in 1988-1991 were approached with questionnaires evaluating their QOL prior to and 3 months and 1, 2, and 5 years after the operation. Three different instruments were used: the Nottingham Health Profile, the Psychological General Well-Being Index, and the Physical Activity Score. RESULTS: In all 2121 patients underwent CABG, of whom 310 died during 5 years of follow-up. With all three instruments QOL had improved 5 years after CABG compared with prior to the operation. However, all three instruments revealed a slight but significant deterioration in estimated QOL between 2 and 5 years after CABG. CONCLUSIONS: QOL 5 years after CABG is better than that prior to the operation, but between 2 and 5 years after the operation a slight deterioration in QOL is observed.     

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.     

Venous thromboembolism, radiology by the organ, combined diagnostic imaging, clinical radiology

OBJECTIVE: To describe mortality and morbidity during a period of 2 years after coronary artery bypass grafting (CABG) in relation to a history of hypertension. PATIENTS: All patients in western Sweden in whom CABG was undertaken between June 1988 and June 1991 and in whom simultaneous valve surgery was not performed were included in the study. DESIGN: A prospective 2-year follow-up study. RESULTS: Patients with a history of hypertension (n = 777) differed from patients without such a history (n = 1348) in that the proportion of women was higher, they were older and more frequently had a history of congestive heart failure, diabetes mellitus, renal dysfunction, cerebro-vascular disease, intermittent claudication and obesity, and the number of smokers and patients with previous CABG was lower. They were also more likely to develop post-operative cerebrovascular complications and signs of myocardia damage. Patients with hypertension tended to have increased mortality during the first 30 days after CABG and the late mortality (between day 30 and 2 years) was significantly higher than in non-hypertensive participants. Whereas the development of myocardial infarction was similar in both groups, the hypertensive study participants more frequently developed stroke during 2 years of follow-up. In a multivariate analysis including age, sex, history of different cardiovascular diseases, smoking, ejection fraction, and the occurrence of three-vessel disease, hypertension did not emerge as an independent predictor of death in the early or late phase or during a total of 2 years of follow-up. CONCLUSION: Among CABG patients, those with a history of hypertension have a different pattern of risk factors. They have a higher mean age, include a higher proportion of women and have a higher prevalence of congestive heart failure, diabetes mellitus, renal dysfunction, cerebro-vascular disease, intermittent claudication, and obesity. They also have an increased frequency of immediate post-operative complications and an increased 2-year mortality, even if a history of hypertension was not an independent predictor of death during 2 years of follow-up.     

Atrial fibrillation after bypass surgery: does the arrhythmia or the characteristics of the patients prolong hospital stay?

STUDY OBJECTIVES: The goal of this study was to determine whether prolonged hospital stay associated with atrial fibrillation or flutter (AF) after coronary artery bypass graft (CABG) surgery is attributable to the characteristics of patients who develop this arrhythmia or to the rhythm disturbance itself. DESIGN: An investigation was conducted through a prospective case series. SETTING: Patients were from a single urban teaching hospital. PARTICIPANTS: Consecutive patients undergoing isolated CABG surgery between December 1994 and May 1996 were included in the study. INTERVENTIONS: No interventions were involved. RESULTS: Of 436 patients undergoing isolated CABG surgery, 101 (23%) developed AF. AF patients were older and more likely to have obstructive lung disease than patients without AF, but both patients with and without AF had similar left ventricular function and extent of coronary disease. ICU and hospital stays were longer in patients with AF. Multivariate analysis, adjusted for age, gender, and race, demonstrated that postoperative hospital stay was 9.2+/-5.3 days in patients with AF and 6.4+/-5.3 days in patients without AF (p<0.001). CONCLUSIONS: Although AF is strongly associated with advanced age, most of the prolonged hospital stay appears to be attributable to the rhythm itself and not to patient characteristics.     

Simultaneous coronary artery bypass grafting and abdominal aneurysm repair decreases stay and costs

BACKGROUND: Patients with large (> or = 5.0 cm) abdominal aortic aneurysms (AAA) frequently have marked associated coronary artery disease. We hypothesized that a single operation for coronary artery bypass grafting (CABG)/AAA would provide equivalent, if not improved, patient care while decreasing postoperative length of stay and hospital costs compared with staged procedures. METHODS: Eleven patients to date have undergone a combined procedure at our institution. Ten underwent CABG followed by AAA repair, whereas one patient received an aortic valve replacement before aneurysm repair. We performed a retrospective analysis comparing the postoperative length of stay and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. RESULTS: No operative mortality has been reported. There were no episodes of neurologic deficit or cardiac complication after these procedures. The postoperative length of stay was significantly decreased for the CABG/AAA group compared with the combined postoperative length of stay for the AAA plus CABG group (7.44+/-0.88 days versus 14.10+/-2.00; p = 0.012). Total hospital costs were also significantly decreased for the CABG/AAA group compared with total hospital costs for the AAA plus CABG group ($22,941+/-$1,933 versus $34,076+/-$2,534; p = 0.003). CONCLUSIONS: A single operation for coronary revascularization and AAA repair is safe and effective. Simultaneous CABG and AAA repair substantially decreases postoperative length of stay and hospital costs while avoiding possible interim aneurysm rupture and repeat anesthesia.     

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.     

The effects of pictorial versus tangible stimuli in stimulus-preference assessments

OBJECTIVES: The purpose of this study was to compare 3-year risk-adjusted survival in patients undergoing coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty. BACKGROUND: Coronary artery bypass graft surgery and angioplasty are two common treatments for coronary artery disease. For referral purposes, it is important to know the relative pattern of survival after hospital discharge for these procedures and to identify patient characteristics that are related to survival. METHODS: New York's CABG surgery and angioplasty registries were used to identify New York patients undergoing CABG surgery and angioplasty from January 1, 1993 to December 31, 1995. Mortality within 3 years of undergoing the procedure (adjusted for patient severity of illness) and subsequent revascularization within 3 years were captured. Three-year mortality rates were adjusted using proportional hazards methods to account for baseline differences in patients' severity of illness. RESULTS: Patients with one-vessel disease with the one vessel not involving the left anterior descending artery (LAD) or with less than 70% LAD stenosis had a statistically significantly longer adjusted 3-year survival with angioplasty (95.3%) than with CABG surgery (92.4%). Patients with proximal LAD stenosis of at least 70% had a statistically significantly longer adjusted 3-year survival with CABG surgery than with angioplasty regardless of the number of coronary vessels diseased. Also, patients with three-vessel disease had a statistically significantly longer adjusted 3-year survival with CABG surgery regardless of proximal LAD disease. Patients with other one-vessel or two-vessel disease had no treatment-related differences in survival. CONCLUSIONS: Treatment-related survival benefit at 3-years in patients with ischemic heart disease is predicted by the anatomic extent and specific site of the disease, as well as by the treatment chosen.     

Female sex is associated with increased mortality and morbidity early, but not late, after coronary artery bypass grafting

OBJECTIVE: To describe mortality and morbidity during a period of 2 years after coronary artery bypass grafting in relation to gender. DESIGN: Prospective follow-up study. SETTING: Two regional cardiothoracic centres which performed all the coronary artery bypass operations in western Sweden at the time. SUBJECTS: A total of 2129 (1727 (81%) men and 402 (19%) women) consecutive patients undergoing coronary artery bypass surgery between June 1988 and June 1991 without concomitant procedures. RESULTS: Females were older and more frequently had a history of hypertension, diabetes mellitus, congestive heart failure, renal dysfunction and obesity. In a multivariate analysis, taking account of age, history of cardiovascular diseases and renal dysfunction, female sex appeared as a significant independent predictor of mortality during the 30 days after coronary artery bypass grafting (P < 0.05), but not thereafter. Various postoperative complications including neurological deficit, hydro- and pneumo-thorax, perioperative myocardial damage and the need for assist devices and prolonged reperfusion were more common in females than males. CONCLUSION: Females run an increased risk of early death and the development of postoperative complications after coronary artery bypass surgery as compared with males. Late mortality does not appear to be influenced by gender and the long-term benefit of the coronary artery bypass graft operation is similar in men and women.     

Report on the antiemetic effectivity of a single 1 mg oral granisetron in moderately emetogenic chemotherapies of gynecological malignancies

OBJECTIVE: This retrospective study was designed to assess the risks of acute ascending aorta dissection (AAD) as a rare but potentially fatal complication of open heart surgery. METHOD: Among 8624 cardiac surgical procedures under cardiopulmonary bypass (CPB) and cardioplegic myocardial protection from 1978 to 1997, 10 patients (0.12%) presented with a secondary or so called 'iatrogenic' AAD. There were seven men and three women, mean age 64 +/- 9 years, ranging from 47 to 79. The original procedures involved five coronary artery bypass grafts (CABG), one repeat CABG, one aortic valve replacement (AVR), one AVR and CABG, one mitral valvuloplasty (MVP) and CABG and one ascending aorta replacement. We retrospectively analyzed their hospital records. RESULTS: Group I consisted of seven patients with AAD intraoperatively and group II consisted of three patients who developed acute AAD 8-32 days after cardiac surgery. In group I, treatment consisted of the original procedure, plus grafting of the ascending aorta in six patients and closed plication and aortic wrapping in one. In group II, two patients received a dacron graft and one patient developed lethal tamponnade due to aortic rupture before surgery. Postoperatively, six patients responded well and three died (33%), two patients from group I on the 2nd postoperative day with severe post-anoxic encephalopathy, and one from group II with severe peroperative cardiogenic shock. CONCLUSION: Preventing AAD with the appropriate means remains standard practice in cardiac surgery. If AAD occurs, it requires prompt diagnosis and interposition graft to allow a better prognosis. Intraoperative AAD happens at the beginning of CPB jeopardizing perfusion of the supra-aortic arteries.     

A case report of infective endocarditis with total rupture of the posterior papillary muscle after aortic valve replacement

We reported a case with severe mitral regurgitation caused by total rupture of the posterior papillary muscle two days after aortic valve replacement. A 62-year-old man was transferred to our hospital with high fever and dyspnea with severe aortic regurgitation caused by infective endocarditis. The left heart failure occurred suddenly two days after the initial operation. Echocardiogram revealed massive mitral regurgitation and rupture of the posterior papillary muscle. He underwent emergent mitral valve replacement. Histological examination of the papillary muscle showed typical ischemic necrosis without inflammation. The postoperative course was uneventful. We suggested the papillary muscle rupture in this case may be due to coronary artery emboli occurred in association with infective endocarditis.     

Long-term outcome when major complications follow coronary artery bypass graft surgery. Recovery after complicated coronary artery bypass graft surgery

OBJECTIVE: To determine whether information available 1 week after surgery correlates with long-term function in patients who suffer major complications after coronary artery bypass graft (CABG) surgery. DESIGN: An inception cohort study. SETTING: A 526-bed community teaching hospital. PATIENTS: All 67 patients who required at least 7 days of CT-ICU care following 2,751 consecutive CABG operations. MAIN OUTCOMES: Hospital survival, long-term survival, and functional ability at long-term follow-up. RESULTS: Forty-three patients survived hospitalization (64%), while 24 died 37 +/- 45 days (range, 7 to 190 days) after surgery. When 42 patients were surveyed 22 +/- 9 months after surgery, 21 of the survivors enjoyed excellent, independent function, 7 were moderately impaired but living at home, 6 were institutionalized with severe limitations, and 8 had died. Patients with very severe cardiac or neurologic dysfunction 1 week after surgery had an extremely poor outcome. When mechanical ventilation was required for causes other than primary failure of the respiratory system, long-term function and hospital survival were poor. Twelve of 14 patients with pulmonary complications survived hospitalization, and all 12 were alive at long-term follow-up. CONCLUSION: More than half of patients requiring 7 days or more of ICU treatment after CABG surgery survive, and many enjoy excellent long-term function. However, those with very severe cardiac or neurologic dysfunction 1 week after surgery have little chance for independent recovery.     

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.     

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.     

Mitral valve replacement and coronary artery bypass grafting for postinfarction mitral papillary muscle rupture

A 79-year-old man was admitted to our hospital with heart failure following acute inferior myocardial infarction. An echocardiogram demonstrated severe mitral insufficiency, and coronary arteriography revealed double vesel disease. Following diagnosis of ischemic papillary muscle dysfunction, PTCA was performed, but the mitral insufficiency was not eliminated. Follow-up echocardiography disclosed rupture of the posterior papillary muscle. He underwent surgery on the 30th day after onset of acute myocardial infarction. Partial rupture of the posterior papillary muscle was found at surgery, and mitral valve replacement and single coronary artery bypass to Lcx were performed. His postoperative course was uneventful, and he was discharged on the 46th day after operation.     

Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting

BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.     

Left main coronary artery stenosis following aortic valve replacement using a solid coronary perfusion catheter: report of two cases

We experienced two cases of iatrogenic left main coronary artery stenosis (IOCS) following double (aortic and mitral) valve replacement (DVR). The solid coronary perfusion catheter may attribute IOCS, with grave consequence. There have been no IOCS since the time we exchanged a solid catheter for a soft one. One case, she was successfully treated percutaneous transluminal coronary angioplasty (PTCA), because she developed angina pectoris about 5 years after PTCA. But she developed angina pectoris again and angiographically left main coronary was severe stenotic. So she was undergone aorto coronary bypass grafting (CABG) to the left anterior descending. The other case, he developed angina pectoris about 3 months after DVR. He was treated with PTCA. Angiographically left mine coronary artery stenosis reduced 50% from 90%. Generally the treatment of IOCS is CABG, but we performed PTCA for 2 patients. Because we thought it was very hazardous for us to perform them open heart surgery. When it is very hazardous to perform patients open heart surgery, they need to be performed PTCA.     

Genetics and pulmonary medicine. 4. Pulmonary embolism

During recent years, coronary bypass surgery has progressed toward minimizing invasiveness. One important feature of this approach is performing surgery on a beating heart. During the crucial phase of such surgery, the mechanical support of the heart with a left ventricular assist device (LVAD) is a possible option. During the period from October 1, 1994 until June 30, 1997, we employed a centrifugal pump system in 118 cases of coronary artery bypass graft (CABG) procedures with LVAD support (mechanically supported CABG [SUPPCAB]). A total of 179 distal anastomoses with an average of 1.5 +/- 0.5 coronary anastomoses per patient was performed. Three types of pumps were used: 23 BioPump, 87 Isoflow, and 8 Capiox systems. The median time on mechanical support was 44 min (range, 16-116 min). The mean flow rate during support time was 3.5 +/- 0.8 L/min, which results in a calculated flow of 1.7 +/- 0.6 L/min/m2 body surface area (BSA). The average flow was 3.2 +/- 0.8 L/min with the BioPump and 3.7 +/- 0.8 L/min with the Isoflow pump, respectively (p < 0.01). The mean arterial pressure during mechanical support was 75 +/- 12 mm Hg. In 2 patients, the pump system was kept running postoperatively in the ICU. Eight of the patients received operations under resuscitation or in cardiogenic shock. Nine (7.9%) of the patients did not survive the early postoperative phase. For coronary revascularization of the anterolateral and diaphragmatic parts of the heart, the SUPPCAB procedure is feasible with excellent mechanical support of the heart by centrifugal pumps. Especially in high risk cases, this procedure can be recommended.     

DNA index by flow cytometric analysis: an additional prognostic factor in advanced ovarian carcinoma without residual disease after primary operation

Prediction of duration of a patient's stay in the ICU after cardiac surgery is difficult. In 652 consecutive adult patients undergoing elective coronary artery bypass graft (CABG) surgery, we analysed prospectively preoperative and immediate postoperative variables thought to influence duration of stay in the ICU. With univariate analysis, we found that age, preoperative left ventricular ejection fraction, bypass time, aortic cross-clamp time, blood transfusions and the number of inotropic agents administered in the immediate postoperative period (for at least 6 h) were significant correlates of duration of stay in the ICU. However, logistic regression analysis showed that the number of inotropes was the most important determinant of stay in the ICU, with an overall prediction accuracy of 94.8%. The main cause of prolonged stay in the ICU (more than 2 days) was low cardiac output syndrome. We conclude that analysis of perioperative variables enhanced our ability to accurately predict duration of stay in the ICU in cardiac surgery patients. The number of inotropic agents administered during the first 6 h after operation was the most important determinant of duration of stay in the ICU.     

Predictors of major in-hospital ischemic complications and length of hospital stay after coronary stenting

Although recent data show that coronary stenting reduces procedural complications and late restenosis, major concern has been expressed about the greater hospital cost associated with the use of this device as compared to conventional coronary angioplasty. Since length of hospital stay after surgical procedures is a major determinant of resource use, the identification of variables associated with an excessively long hospital stay after intracoronary stent placement may have important practical consequences. The purpose of this study was to assess factors responsible for the occurrence of in-hospital complications and prolonged hospital stay after coronary stenting in 939 consecutive patients enrolled in the Registro Impianto Stent Endocoronarico (RISE Study Group). Consecutive patients undergoing coronary stent implantation at 16 medical centers in Italy were prospectively enrolled in the Registry. Clinical data, qualitative and quantitative angiographic findings were obtained from data collected in case report forms at each investigator site. Major ischemic complications were considered death, Q-wave myocardial infarction, emergency bypass surgery and emergency repeat angioplasty. The study group consisted of 939 patients (781 men, 158 women with a mean age of 59 years) in whom 1392 stents were implanted in 1006 lesions and expanded at a maximal inflation pressure of 14.7 +/- 3 atmospheres. The great majority of patients (92%) received only antiplatelet drugs after coronary stenting. During hospitalization, there were 45 major ischemic complications in 39 patients (4.2%): 13 events were related to acute or subacute thrombosis (1.4%). On multivariate logistic regression analysis, the following factors were predictive of in-hospital complications: increasing age (OR 2.19, 95% CI 1.18-4.07), unplanned stenting (OR 3.46, 95% CI 1.65-7.23) and maximal inflation pressure (OR 0.83, 95% CI 0.75-0.93). Mean hospital stay after stent implantation was 4.1 +/- 4.4 days and was related, by multivariate regression analysis, to female sex (p = 0.0001), prior bypass surgery (p = 0.03), non-elective stenting (p = 0.0001), use of anticoagulation (p = 0.0001) and development of major ischemic complications (p = 0.0001). This Registry shows that in an unselected population of patients undergoing coronary stenting, major ischemic complications occur at a relatively low rate (4.2%) and thrombotic events can be kept at 1.4%, despite the omission of anticoagulation in the great majority of patients. Length of hospital stay was affected by the occurrence of major ischemic complications, unplanned stenting, use of anticoagulation, female sex and prior bypass surgery. Accumulating experience, further reduction in complications and complete omission of anticoagulation may decrease length of hospital stay, thus reducing the use of resources after coronary stenting.