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.     

Complete direct mammary harvest for minimally invasive coronary artery bypass

Minimally invasive coronary artery bypass has primarily involved left internal mammary artery grafting to the left anterior descending coronary artery through a small left anterior thoracotomy incision. Harvesting of the mammary artery has been accomplished completely using a video-assisted thoracoscopic technique or incompletely to the second interspace under direct vision. With a mammary retractor, the mammary artery can be dissected completely under direct vision, thus eliminating any criticism of an incomplete harvest and any increased difficulty or expense associated with the thoracoscopic harvest. In this series, all 17 mammary arteries were successfully harvested completely under direct vision and 16 patients underwent successful minimally invasive coronary bypass.     

Outcome of coronary bypass surgery versus coronary angioplasty in diabetic patients with multivessel coronary artery disease

The coloration of cells of the cyanobacterium Synechococcus sp. PCC 7002 changed from normal blue-green to yellow-green when cells were grown at 15 degrees C in a medium containing nitrate as the sole nitrogen source. This change of coloration was similar to a general response to nutrient deprivation (chlorosis). For the chlorotic cells at 15 degrees C, the total amounts of phycobiliproteins and chlorophyll a decreased, high levels of glycogen accumulated, and growth was arithmetic rather than exponential. These changes in composition and growth occurred in cells grown at low (50 microE m-2 s-1) as well as high (250 microE m-2 s-1) light intensity. After a temperature shift-up to 38 degrees C, chlorotic cells rapidly regained their normal blue-green coloration and normal exponential growth rate within 7 h. When cells were grown at 15 degrees C in a medium containing urea as the reduced nitrogen source, cells grew exponentially and the symptoms of chlorosis were not observed. The decrease in photosynthetic oxygen evolution activity at low temperature was much smaller than the decrease in growth rate for cells grown on nitrate as the nitrogen source. These studies demonstrate that low-temperature-induced chlorosis of Synechococcus sp. PCC 7002 is caused by nitrogen limitation and is not the result of limited photosynthetic activity or photodamage to the photosynthetic apparatus, and that nitrogen assimilation is an important aspect of the low-temperature physiology of cyanobacteria.     

Fluid therapy with Ringer's solution versus Haemaccel following coronary artery bypass surgery

BACKGROUND: Crystalloid and colloid infusion can be used in volume therapy following heart surgery. In this prospective, randomised study we compared Ringer's solution (group R) to Haemaccel (group H) following coronary artery bypass grafting. METHODS: A stringent protocol for adjusting the infusion rate was used. Haemodynamic parameters and pulmonary function were evaluated as well as chest tube drainage. The double-indicator dilution method was used to measure total blood volume index (TBVI), intrathoracic blood volume index (ITB-VI) and extravascular lung water index (EVLWI). RESULTS: Haemodynamic stability was achieved in both groups throughout the study period, as judged from mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, and cardiac index. However, the total volume infused was significantly higher in group R. TBVI and ITBV were higher in group H, although only significant at 8 h for TBVI. Pulmonary function was similar in both groups. There was no significant difference in EVLWI, pulmonary shunt fraction, and time on mechanical ventilation. Likewise, chest tube drainage was not significantly different in both groups. CONCLUSION: We conclude that volume therapy with Haemaccel following heart surgery requires less volume and achieves better filling of the circulation compared to Ringer's solution.     

Laparoscopic versus open surgery for colorectal cancer

There are three basic roles of laparoscopic surgery for patients with colorectal cancer. First, although infrequently needed prior to therapy, diagnostic or staging laparoscopy may be valuable in certain colorectal cancer patients. Second, the laparoscopic approach may offer several attractive features for the palliative management of patients with incurable colorectal cancer. Finally, although this issue is the most controversial, there are theoretic but unproved advantages of using laparoscopic techniques for curative colorectal cancer therapy. The concerted efforts of surgical oncologists and their colleagues must prove this theory in well constructed trials.     

Harmonic scalpel in coronary artery bypass surgery

The startup performance of medical linear accelerators is of increasing importance for modern radiotherapy techniques. The traveling wave-type linear accelerator of the SL series of Philips (now Elekta Oncology Systems) has been modified in its flight tube design to meet this goal of a fast rise time of the radiation field. The new slitless flight tube combined with a redesigned gun servo electronic now achieves start up times of the radiation comparable with those of a standing wave linear accelerator (Siemens Mevatron) according to our measurements.     

Neuropsychological disorders after coronary bypass surgery

Pettegrew et al (Arch Gen Psychiatry 48:563-568, 1991) were the first to determine abnormalities concerning phospholipids and high energy metabolites in the dorsolateral prefrontal cortex of drug-naive schizophrenics with 31P magnetic resonance spectroscopy (MRS). Other investigations could not replicate these findings. We included in our study 13 schizophrenic inpatients and 14 age-matched controls. Whereas Pettegrew et al found increased levels of phosphodiesters and decreased levels of phosphomonoesters we measured decreased levels of phosphodiesters in the schizophrenics as compared to controls. One possible explanation for the contradictory findings of the both trials might be the different localization techniques used.     

Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting

BACKGROUND: Epidemiologic studies have shown dietary antioxidants to be inversely correlated with ischemic heart disease. OBJECTIVE: We investigated whether dietary beta-carotene, vitamin C, and vitamin E were related to the risk of myocardial infarction (MI) in an elderly population. DESIGN: The study sample consisted of 4802 participants of the Rotterdam Study aged 55-95 y who were free of MI at baseline and for whom dietary data assessed by a semiquantitative food frequency questionnaire were available. During a 4-y follow-up period, 124 subjects had an MI. The association between energy-adjusted beta-carotene, vitamin C, and vitamin E intakes and risk of MI was examined by multivariate logistic regression. RESULTS: Risk of MI for the highest compared with the lowest tertile of beta-carotene intake was 0.55 (95% CI: 0.34, 0.83; P for trend = 0.013), adjusted for age, sex, body mass index, pack-years, income, education, alcohol intake, energy-adjusted intakes of vitamin C and E, and use of antioxidative vitamin supplements. When beta-carotene intakes from supplements were considered, the inverse relation with risk of MI was slightly more pronounced. Stratification by smoking status indicated that the association was most evident in current and former smokers. No association with risk of MI was observed for dietary vitamin C and vitamin E. CONCLUSION: The results of this observational study in the elderly population of the Rotterdam Study support the hypothesis that high dietary beta-carotene intakes may protect against cardiovascular disease. We did not observe an association between vitamin C or vitamin E and MI.     

Central venous catheter use in low-risk coronary artery bypass grafting

BACKGROUND: To assess the impact of central venous pressure catheter monitoring in low-risk coronary artery bypass grafting (CABG), we compared the hospital course of patients undergoing CABG with central venous pressure catheter monitoring with that of similar patients undergoing CABG with pulmonary artery catheter monitoring. METHODS: All isolated primary CABG procedures (n = 312) performed between April 22 and October 31, 1996, were evaluated, and 194 patients meeting six central venous pressure catheter use criteria were identified. Of these 194 patients, 133 (68%) underwent CABG with central venous pressure catheter monitoring, and 61 (32%) had pulmonary artery catheter monitoring owing to surgeon or anesthesiologist preference. RESULTS: In-hospital mortality was similar. A trend toward increased overall complications was seen in the pulmonary artery catheter group. The total volume infused in the first 12 hours, the 24-hour weight gain, and the intubation time were significantly greater in the pulmonary artery catheter group. Increases in intensive care unit length of stay and in total hospital charges trended toward statistical significance in the pulmonary artery catheter group. CONCLUSIONS: Pulmonary artery catheter use in low-risk patients undergoing CABG was associated with greater weight gain and longer intubation time and may be associated with increased morbidity and utilization of hospital resources.     

Revascularization in patients with prior coronary bypass surgery

Increasingly over the past several years, patients have returned after coronary surgery for reintervention procedures. This reflects immediate postsurgical complications and the relentless progression of coronary artery disease in the native circulation and in the bypass grafts. Although there are randomized comparative data for coronary bypass surgery (CABG) versus percutaneous transluminal coronary angioplasty (PTCA) and medical therapy, these trials have always excluded patients with previous (GABG). OBJECTIVES: We attempted to compare the 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). METHODS AND RESULTS: This study examines follow up data (15.4 +/- 11.0 months) from 130 patients with previous CABG, who required either PTCA (Group A, n = 73) or re-CABG (Group B; n = 57) at a single center from 1994 to 1997. Follow up data were obtained from subsequent office visits and telephone calls. The PTCA and re-CABG groups were similar with respect to gender (86% vs 94% males), mean age (62 +/- 9 vs 59 +/- 10 years), angina CCS classes 3 and 4 (73% vs 69%), diminished left ventricular function (23% vs 26%), risk factors such as diabetes (19% vs 17%), hypercolesterolemia (49% vs 45%) and smoking (48% vs 39%) and three-vessel native coronary artery disease (67% vs 72%). The symptomatic status prior to the revascularization procedure was similar in both groups. Complete and functional revascularization was achieved in 85% of the PTCA group and in 92% of those with re-CABG (p = NS). During the hospital stay the complication rates were lower in the PTCA group. Actuarial survival was different at follow up (p = 0.04). Both PTCA and re-CABG groups resulted in equivalent event-free survival (freedom from death, myocardial infarction, unstable angina and urgent revascularization). The need for repeat revascularization at follow up was significantly higher in the PTCA group (PTCA 28% vs re-CABG 10%, p < 0.01). CONCLUSIONS: In this non-randomized study of patients with previous CABG requiring revascularization procedures, PTCA resulted in lower procedural morbidity and mortality risks. At follow up, both PTCA or CABG were similar for event-free survival; PTCA offered lower overall mortality, although it is associated to a greater need for subsequent revascularization procedures.     

Video-assisted coronary bypass surgery: clinical results

The pesticide residues 1-(o-chlorophenyl)-1-(p-chlorophenyl)-2,2,2-trichloroethane (o,p'-DDT) and beta-hexachlorocyclohexane (beta-HCH) act as weak estrogens, producing uterotrophic responses in ovariectomized rodents and stimulating human breast cancer cells in culture. Such activity suggests that these compounds may act as tumor promoters in estrogen-responsive tissues. Organochlorine compounds such as o,p'-DDT and beta-HCH are concentrated in body fat. The present report tests whether sufficient compound can be released from fat depots to produce estrogenic effects in uteri of ovariectomized mice. Adult animals were "loaded" with test compound by three daily injections of vehicle (DMSO), 17beta-estradiol (E2), beta-HCH, or o,p'-DDT. Uterotrophic effects were assessed at 24 h after the last loading dose of test compound and at 2 weeks after the loading regimen, with or without a prior 2-day period of fasting. The initial 3-day treatment with either beta-HCH or o,p'-DDT doubled the relative dry weight of the uterus: 102 +/- 8.6 mg/kg body weight (BW) and 104 +/- 4.4 mg/kg BW for beta-HCH and o,p'-DDT, respectively, compared to 49 +/- 1.9 mg/kg BW for vehicle-treated animals. E2-treated animals had uterine dry weights of 228 +/- 11 mg/kg BW. After 2 weeks without further treatment, a 2-day fast produced a decrease in body mass of 4.1 g/animal (fasted, 25.9 +/- 1.89 g versus fed, 30.0 +/- 2.82 g). Animals that had been loaded with beta-HCH and fasted had uterine weights (88 +/- 12 mg/kg BW) significantly greater (P < 0.05) than those of vehicle-loaded, fasted animals (51 +/- 2.9 mg/kg BW) or of beta-HCH-loaded, fed animals (59 +/- 4.6 mg/kg BW). The uterine weights of the fasted and fed o,p'-DDT-loaded or E2-loaded animals were not different from those of control weights. The difference between wet and dry weights showed that fasting of beta-HCH-loaded animals also increased water imbibition in the uterus; there was no effect from fasting in the other groups. Generally, epithelial cell height reflected the same responses as uterine weight with the exception that cell heights of beta-HCH-loaded, fed animals were slightly higher (P < 0.05) than corresponding controls, indicating that there may have been some active compound available to the tissues even without fasting. The effects of fasting show that during periods of lipolysis beta-HCH can be released in quantities sufficient to stimulate estrogen target tissues, suggesting a novel mechanism linking obesity and the progression of estrogen-responsive tumors. The lack of effect from fasting in o,p'-DDT-loaded animals indicates that these compounds are differentially mobilized from fat depots.     

Minimally invasive direct coronary artery bypass surgery

Traditional coronary artery bypass surgery involves a median sternotomy and the use of a heart-lung machine to stabilize the heart during suturing. Minimally invasive coronary artery surgery employs small incisions directly over the target vessels and avoids the use of a heart-lung machine, which can cause postoperative complications. The target coronary vessels are stabilized in alternative ways, potentially hazardous manipulation of the ascending aorta is avoided, and the subclavian and axillary arteries provide alternative inflow sources. Other new techniques used in minimally invasive procedures include a coronary artery cannula to avoid intraoperative ischemia and wound irrigation catheters to administer postoperative bupivacaine hydrochloride. Perioperative nurses need to become familiar with these new techniques to be able to plan and implement effective patient care.     

Managing pain after coronary artery bypass surgery

From June 1992 to May 1993, rotaviruses were detected by an immunoenzymatic assay in 159 (49.5%) of 321 children admitted to the hospital with acute diarrhea. Of the 159 cases ELISA positive, 80 samples were chosen at random to investigate subgroups and serotypes of group A human rotavirus. By the ELISA test 9 (11.3%) of the strains were subgroup I, 46 (57.5%) were subgroup II, and 25 (31.3%) could not be grouped. The serotype G1 was identified in 52 cases (65%), G2 in 11 cases (13.8%), G3 in 1 case (1.2%), and 7 cases (8.8%) showed more than one serotype. By electrophoretic analysis of viral RNA, 137 (42.7%) of the samples exhibited an RNA pattern. The long pattern (59.1%) prevailed over the short pattern (35.8%), and by coelectrophoresis 8 different electropherotypes were found throughout the period of study. These results illustrate the great variety of rotavirus strains in this region of the country.     

The gastroepiploic artery graft in coronary artery bypass surgery

From March 1986 to October 1989, 91 patients underwent CABG using the right gastroepiploic artery (GEA) at Osaka Medical College and Mitsui Memorial Hospital. Including 14 females, the mean age was 57.9 years old ranged from 34 to 73 years old. Triple vessel disease and left main disease occupied over 90% of the patients. There were 5 emergency operations and 6 reoperations. Associated serious diseases were; renal failure with hemodialysis in 2 pts., familial hyperlipidemia in 5 pts., severe atherosclerotic ascending aorta in 8 pts., arteriosclerosis obliterance in 3 pts., and each one of abdominal aortic aneurysm and idiopathic thrombocytopenic purpura. The internal thoracic artery (ITA) graft was concomitantly utilized in 96% of the patients. Single ITA in 60 pts., double ITA in 23 pts. and sequential ITA in 5 patients. Saphenous vein graft was used in 58 patients and remaining 33 patients were operated without leg wound. The mean number of distal anastomoses was 3.3 ranged from 1 to 5, and the mean number of arterial grafts was 2.5 ranged from 1 to 4. The mean aortic cross clamp time and cardiopulmonary bypass time was 62.8 minutes and 113.6 minutes, respectively. Sites of GEA anastomosis were; 4 anterior descending, 3 diagonal, 11 circumflex and 73 right coronary arteries. There were 86 in situ grafts mostly for the right coronary arteries, and remaining 5 GEAs were used as a free graft to bypass the left coronary arteries. On the contrary, ITA was used to bypass the left coronary artery system preferentially. There was 3 combined procedures; splenectomy, abdominal aorta replacement, and ascending aorta to bifemoral artery bypass in each one patients. Three patients including one emergency case died within 30 days after surgery. Two were cardiac and one was renal failure. Other 2 patients died of stroke at late period. New Q wave infarction was noted in 2 patients. Relief of angina was obtained in 98% of survivors. The patency rate of the GEA graft was 97% in 61 grafts restudied within 6 postoperative months, which was identical with that of the ITA graft, that is 97% of 76 grafts. In conclusion, the GEA has several advantages as a coronary artery bypass graft such as similarity in size to the coronary artery, rare arteriosclerosis, feasibility of in situ graft, and no gastric complication. Its flow capacity is studying now and favourable results are being obtained. The final problem, its long term patency, will be resolved in future. GEA is a promising conduit for the coronary bypass surgery.     

Landmarks in the development of coronary artery bypass surgery

Genetic linkage maps have been produced for a wide range of organisms during the last decade, thanks to the increasing availability of molecular markers. The use of microsatellites (or Simple Sequence Repeats, SSRs) as genetic markers has led to the construction of "second-generation" genetic maps for humans, mouse and other organisms of major importance. We constructed a second-generation single-tree genetic linkage map of Norway spruce (Picea abies K.) using a panel of 72 haploid megagametophytes with a total of 447 segregating bands [366 Amplified Fragment Length Polymorphisms (AFLPs), 20 Selective Amplification of Microsatellite Polymorphic Loci (SAMPLs) and 61 SSRs, each single band being treated initially as a dominant marker]. Four hundred and thirteen markers were mapped in 29 linkage groups (including triplets and doublets) covering a genetic length of 2198.3 cM, which represents 77.4% of the estimated genome length of Picea abies (approximately 2839 cM). The map is still far from coalescing into the expected 12 chromosomal linkage groups of Norway spruce (2n = 2x = 24). A possible explanation for this comes from the observed non-random distribution of markers in the framework map. Thirty-eight SSR marker loci could be mapped onto 19 linkage groups. This set of highly informative Sequence Tagged Sites (STSs) can be used in many aspects of genetic analysis of forest trees, such as marker-assisted selection, QTL mapping, positional cloning, gene flow analysis, mating system analysis and genetic diversity studies.     

Outcomes of coronary artery bypass surgery in elderly people

The role of non-invasive nocturnal domiciliary ventilation (NNV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnia is still discussed. The aims of this study were to evaluate the long-term survival, the clinical effectiveness and side-effects of NNV in these patients. Forty-nine stable hypercapnic COPD patients on long-term oxygen therapy (LTOT) were assigned to two groups: in Group 1, 28 patients performed NNV by pressure support modality in addition to LTOT; in Group 2, 21 patients continued their usual LTOT regimen. Treatment was assigned according to the compliance to NNV, after an in hospital period. Mortality rate, hospital stay (HS) and ICU admissions (IA) were recorded in the two groups. HS and IA were compared to those recorded in a similar period of follow-back. Lung and respiratory muscle function, dyspnoea, and exercise capacity (by 6-min walk test) were evaluated baseline and every 3-6 months up to 3 yr. Mean follow-up time was 35 +/- 7 months. Mortality rate was not different between the two groups: 16, 33, 46% and 13, 28, 50% at 1, 2 and 3 yr in Groups 1 and 2 respectively. Lung and respiratory muscle function did not significantly change over time. A significant increase in 6-min walk test (from 245 +/- 78 to 250 +/- 88, 291 +/- 75, 284 +/- 89 m after 1, 2 and 3 yr respectively, P < 0.01) was observed only in patients undergoing NNV. In comparison to the follow back HS significantly decreased in both groups (from 37 +/- 29 to 15 +/- 12 and from 32 +/- 18 to 17 +/- 11 days/pt/yr in Groups 1 and 2 respectively, P < 0.001) whereas IA significantly decreased only in patients performing also NNV (from 1.0 +/- 0.7 to 0.2 +/- 0.3/pt/yr, P < 0.0001). Addition of NNV by pressure support modality to LTOT does not improve long term survival but significantly reduces ICU admissions and improves exercise capacity in severe COPD with hypercapnia.     

Aprotinin in patients having coronary artery bypass graft surgery

Any therapy must have a benefit and a risk. The benefit of aprotinin therapy in reducing bleeding is well known. Data presented over the past 12 months have confirmed this efficacy and the superiority and consistency of aprotinin therapy in direct comparison with other pharmacologic (desmopressin, tranexamic acid) and physical (administration of fresh platelet concentrate) interventions. The debate has now changed to focus on issues of the safety of this agent. In particular, concerns have been expressed as to the effect of this agent on renal function, thrombotic potential (and thus graft patency), and adverse reactions on a second exposure. Most recent reports show plasma creatinine concentrations are higher in treated than in nontreated patients on the 3rd or 4th postoperative day. The concentrations reached were not outside the clinical range, and there were no clinical sequelae of this biochemical abnormality. Focused studies have shown no effect of the use of aprotinin therapy on early graft patency or the incidence of thromboembolic complications. The reporting of hypersensitivity reactions following aprotinin administration suggests that the incidence is not different to other agents used in open heart surgery. Three reports of fatal or near-fatal cardiovascular collapse associated with the use of aprotinin followed the apparently inappropriate administration of the agent.     

Vein harvest ischemia: a peripheral vascular complication of coronary artery bypass grafting

Lower-extremity ischemia can lead to impaired healing of saphenous vein excision sites in patients with significant peripheral vascular disease (PVD). Five patients who required infrainguinal revascularization for wound necrosis of the harvest site after coronary artery bypass grafting are described. The male/female ratio was 2:3 with a mean age of 67 (range 45-87) years. The most commonly associated problems were insulin-dependent diabetes mellitus (80%) and congestive heart failure (60%). The saphenous vein was harvested from the thigh and leg in three patients and exclusively from the leg in the others. Manifestations of ischemia ranged from persistent ulceration to complete wound disruption threatening limb loss. Impaired healing was isolated to infragenicular wounds in all patients. Pedal pulses were not detected in any of the affected extremities. Determination of the ankle/brachial pressure indices (ABI) revealed values of < 0.5 in three affected limbs. Non-compressible vessels resulted in falsely raised ABI of > 1.0 in the remaining two limbs; however, Doppler waveform analysis in these patients demonstrated significant PVD. Aggressive wound care and antibiotic therapy were continued for mean of 9 weeks before operative intervention. Infrainguinal reconstruction included femoropopliteal (two), femorotibial (two) and popliteal-tibial bypass (one). Autologous arm and saphenous veins in addition to expanded polytetrafluoroethylene grafts were used effectively. Limb salvage and wound healing were achieved in 100% of the patients without untoward sequelae. It is concluded that unrecognized PVD in patients undergoing coronary artery bypass grafting can lead to significant morbidity. Patients at risk may be identified with a combination of history, physical examination and non-invasive testing.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.