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.     

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.     

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.     

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.     

Mesenteric traction syndrome during coronary artery bypass graft surgery

Mesenteric traction syndrome (MTS) consists of decreased systemic vascular resistance, increased cardiac output, facial flushing and palmar erythema. Local production of PGI2 is thought to be the cause. We experienced a rare case of MTS that occurred during coronary artery bypass graft surgery (CABG). A 64-year-old man was scheduled for CABG for the treatment of angina pectoris. Hemodynamic variables were stable until 50 minutes after surgical incision. Blood pressure fell down suddenly from 110/50 to 70/40 mmHg, accompanied by obvious facial flushing and palmar erythema, when the surgeons were preparing the right gastroepiploic artery. Hemodynamic changes and cutaneous hyperemia returned to the baseline level in about 40 minutes. After this episode, the operation was performed uneventfully. The time sequence between the onset of the surgical procedure and the hemodynamic and cutaneous findings strongly suggest the release of PGI2 and MTS. In patients undergoing CABG with the gastroepiploic artery graft, pretreatment with NSAID might avoid sudden circulatory changes of MTS.     

Acute ischemic syndromes following coronary artery bypass graft surgery

METHODS: In 146 eyes/patients who underwent Nd:YAG laser iridotomy after glaucomatous attack or after prophylactic iridotomy, we evaluated whether the frequency of posterior synechiae depends on (1) glaucomatous attack, (2) preoperative miotic therapy, (3) postoperative antiglaucomatous therapy or (4) mode of intraoperative laser therapy. Out of 616 eyes with YAG iridotomy between 1983 and 1987, 146 eyes/patients fulfilled the inclusion criteria: observation time of minimum 3 months after iridotomy, preoperative examination without signs of preexisting synechiae, postoperative examination at discharge and a later control examination in mydriasis to exclude posterior synechiae. RESULTS: Eyes with and without glaucomatous attack and eyes with an without pre-operative long-term miotic therapy showed no significant difference in frequency of posterior synechiae. Eyes with postoperative long-term therapy with miotics or beta-blockers showed posterior synechiae significantly more often than eyes without post-operative miotic or beta-blocker therapy. Eyes that received DPE in the early post-operative period developed posterior synechiae significantly less often. The number of laser pulses and the mean total energy used were significantly higher in eyes which later developed posterior synechiae. In the group of patients with glaucomatous attack women outnumbered men by four to one, but there was no significant difference in refraction between women and men. CONCLUSIONS: Patients with glaucomatous attack are not at a higher risk of developing posterior synechiae than those without glaucomatous attack. Post-operative antiglaucomatous therapy, the number of laser pulses and the total energy alter the frequency of postoperatively developed posterior synechiae.     

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.     

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 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.     

Residual cognitive dysfunctioning at 6 months following coronary artery bypass graft surgery

Neuropsychological testing is a sensitive method for quantitative assessment of cognitive dysfunctioning following cardiopulmonary bypass (CPB). However, the methodological problems associated with this method, such as learning effects due to repeated testing and the effects of distress on test performance, have often been underestimated. In this study, these confounding effects were controlled for by including the spouses of patients, exposed to the same potential stress effects associated with the operation, as a nonsurgical control group. The experimental group consisted of 63 patients (40-75 years) undergoing elective coronary artery bypass graft (CABG) surgery. A battery of standardized neuropsychological tests was administered to both groups 2 weeks preoperatively and 1 week, 1 month, and 6 months postoperatively. Statistical testing of inter-group differences in preoperative to postoperative changes in test performance revealed the following results: (1) For immediate memory and learning, in general test scores showed the same time course for both groups. (2) For recent memory, patients' scores showed a significant deterioration at 1 month after CABG surgery compared with the scores of spouses. This effect had not completely disappeared at 6 months postoperatively. (3) For attention and psychomotor speed as well as verbal fluency, patients' scores had deteriorated significantly at 1 week after surgery, with incomplete recovery at 6 months. These negative cognitive effects were not related to the patients' ages or CPB parameters (duration of CPB, aortic cross-clamp time, mean flow and arterial pressure during CPB and aortic cross-clamping, and minimum nasopharyngeal temperature). No differences in self-ratings of mood over time were found between the patients and spouses. The results indicate that, when adequately controlling for the effects of learning and distress, some cognitive functions are still impaired at 6 months after CABG surgery.     

Urgent coronary artery bypass surgery by only arterial graft for acute myocardial infarction

The authors conducted urgent coronary artery bypass grafting (CABG) using only arterial graft for mild and moderate acute myocardial infarction (AMI) in 9 cases from January, 1995 through December, 1996. Mild and moderate AMI means free from cardiogenic shock by catecholamines alone or catecholamines and intra aortic balloon pumping (IABP). The period from the onset of AMI to admission was 2-24 (average 8 +/- 6) hours. Coronary arteriography (CAG) was performed immediately following admission. CABG was done immediately after CAG. CPK-MB on admission was 14-184 (average 67 +/- 61) IU/l. Three cases were main trunk disease over 90% stenosis, three cases were main trunk disease equivalent if another stenotic lesion over 99% were occluded, three cases would fall into cardiogenic shock if another stenotic lesion over 99% were occluded. Postoperative IABP was necessary for three cases. No case required repetition of IABP. For minimal operation time and to attain high graft flow, saphenous vein (SV) graft are generally used for emergencies. CABG was conducted here using only arterial graft (Mean anastomosis number was 2.3). There were 8 RITA grafts, 9 LITA grafts, and 4 RGEA grafts. Post operative CAG showed all the grafts to be patent, but string sign was noted for two LITA grafts. Prognosis was favorable in all cases. We could conduct urgent CABG surgery safely for mild and moderate AMI using only arterial grafts.     

Two cases of total arch replacement after coronary artery bypass surgery with internal mammary artery graft

We report two successful cases of total arch replacement after coronary artery bypass surgery (CABG) using internal mammary artery graft (ITA). Case 1 had a true aneurysm of the distal aortic arch occurring 7 years after CABG using left ITA, and case 2 had a dissecting aneurysm of DeBakey II occurring 10 months after CABG using right ITA. This patient was also complicated by a preexisting true aneurysm of the proximal descending aorta. Both cases were managed by repeat midsternal incision, selective cerebral perfusion (SCP) and retrograde cardioplegia. In both cases, functioning ITAs were dissected out easily without injury, and an operative filed for total arch replacement was well obtained under the cardioplegia and brain protection mentioned above.     

Predictors of long-term change in functional status after coronary artery bypass graft surgery in women

A cohort of 164 women who had undergone coronary artery bypass graft surgery (CABG) was followed for one year to examine changes in functional status and determine the relative influence of clinical, psychosocial and sociodemographic factors on change in functional status outcomes between 6 and 12 months after surgery. Clinical, psychosocial, sociodemographic and preoperative functional status data were collected by written questionnaire and personal interview at the time of surgery and again at 6 and 12 months after CABG. Functional status scores improved significantly from before to 6 months after CABG. Between 6 and 12 months post-CABG 65% sustained or continued to experience improvement in physical functioning, 83% in social and leisure activities, and 54% in psychological functioning. Predictors of sustained improvement in physical functioning were being married, younger age, low 6-month functioning, having an ejection fraction of 50% or greater, and being white. The significant predictors of sustained improvement in social and leisure activities and psychological functioning were being married and low 6-month psychological functioning, respectively. These data suggest that interventions to improve long-term outcomes in women undergoing CABG should take into account not only their age, functional capacity and level of functioning at 6 months post-CABG, but also their race and marital status as potential risk factors for long-term functional status disability.     

Coronary angioplasty, bypass surgery, and retransplantation in cardiac transplant patients with graft coronary disease

BACKGROUND AND OBJECTIVE: Prior studies of laser tissue soldering (LTS) of epithelial skin have shown poor wound strength in the short-term; however, we hypothesize that greater tensile strength and healing properties will result from directing laser energy to the dermal aspect of the skin. The current study compares wound strength and histology in a rat skin flap model of epithelial and dermally applied LTS. STUDY DESIGN/MATERIALS AND METHODS: Skin flaps (2.5 x 4 cm) were raised and bisected on the dorsum of Sprague-Dawley rats. The center line of bisection was closed from a dermal approach by LTS (LTS-D, diode laser 15.9 W/cm2 + Columbia solder), the upper incision by epithelial LTS (LTS-E), and the lower incision by suturing (7-0 Vicryl). Wound skin strips (1-2 mm x 10 mm) were studied immediately (N = 14) and at 3 (N = 57), 7 (N = 31), and 10 (N = 28) days postoperatively and were subjected to tensiometric analysis. Histologic staining with hematoxylin and eosin and Mallory's trichrome methods were used to define wound architecture. RESULTS: No wound dehiscences were noted in any group. Greater immediate tensile strength was noted in wounds closed by LTS-D (521 +/- 61 g/cm2) versus LTS-E (342 +/- 65 g/cm2); however, this difference was not statistically significant (P = .08). By 3 days, both LTS-D (476 +/- 55 g/cm2) and LTS-E (205 +/- 37 g/cm2) maintained their initial strength; however, LTS-D and sutured (436 +/- 49 g/cm2) wounds were stronger (P < .05) than LTS-E. At 7 and 10 days, LTS-D (2,433 +/- 346 g/cm2 and 3,100 +/- 390 g/cm2) showed superior tensile strength (P < .05) compared to both LTS-E (1,542 +/- 128 g/cm2 and 2,081 +/- 219 g/cm2) and suturing (1,342 +/- 119 g/cm2 and 1,661 +/- 115 g/cm2). Histologic analysis of LTS-D wounds at 3 days showed full-thickness tissue apposition, complete epithelialization, and minimal inflammation or thermal injury. At 7 days, solder was present in the wounds. In contrast, LTS-E wounds at 3 days displayed lack of epithelialization secondary to thermal injury and partial-thickness tissue apposition. However by 7 days, epithelialization was complete with moderate scarring, and no solder was seen. Sutured samples appeared similar to LTS-D, except for poorer tissue apposition at the hypodermis. CONCLUSION: Our results show that skin flap wound healing after dermal LTS is superior to epithelial LTS and emphasizes the importance of site specificity in the utilization of this operative technique in reconstructive surgery.