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.     

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.     

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.     

Hybrid-type stabilizer for off-pump direct coronary artery bypass grafting

We have developed a mechanical stabilizer for use in off-pump direct coronary artery bypass grafting. We consider it an improvement on the sucker-type stabilizer, although it uses the mechanisms of the compressor-type. Our hybrid stabilizer effectively immobilizes the local heart surface with light compression and low evacuation. We believe that its use will eliminate the need for further immobilization and thus reduce cardiac invasiveness.     

Mesh tube-calibrated varicose veins for coronary artery bypass grafting

Complex arterial bypass grafting may be contraindicated for patients with multivessel disease and inadequate saphenous veins. In such cases varicose veins may be used as bypass conduits after calibration by insertion into mesh tubes. After in vitro and experimental testing, as well as gratifying results in infrainguinal arterial reconstructions, wrapped varicose vein grafts in addition to arterial bypass grafts were used in 6 patients undergoing coronary artery bypass grafting.     

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.     

Patient recovery after infrainguinal bypass grafting for limb salvage

PURPOSE: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.     

Local complications after arterial bypass grafting

We have documented prospectively the problems occurring after 496 arterial bypass grafts (149 aortoiliac, 238 femorodistal, 65 extra-anatomic, and 44 others) implanted during the period 1987 to 1991 in a district general hospital. Postoperative bleeding occurred early in 14 (2.8%), and later (because of infection) in 3 (0.6%). Early graft occlusion (< 30 days) was seen in 2.9% aortofemoral, 10.4% femoropopliteal, and 25.3% femorotibial grafts, and amputation was required after 6.9% grafts. Wound problems were most common after femorotibial bypass--weeping of fluid in 3% and dehiscence or infection in 13.9%. Lymphatic collections occurred after 1.2% operations involving groin incisions. Graft sepsis was usually late, affecting 6% aortofemoral, 2.9% femorodistal, and 7.7% extra-anatomic grafts, but no intra-abdominal aortic grafts. These figures are probably representative of the complication rates seen by many surgeons and serve as an example for comparison and criticism.     

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.     

Video-assisted endoscopic saphenous vein harvesting for coronary artery bypass grafting

OBJECTIVE: Correlation of immunophenotype with history, anatomical and morphological features of lymphoid neoplasia in the koala. METHODS: Routine necropsies were performed on 51 koalas with suspected lymphoid neoplasia between 1986 and 1997 in New South Wales and Queensland. Immunophenotyping was by an immunoperoxidase method utilising species cross-reactive antibodies raised against human lymphocytes and an antibody raised against koala IgG. Cases were classified according to organs and tissues affected and the morphological features of neoplastic cells. RESULTS: Twenty-six (51%) of the cases were of the T cell immunophenotype, 12 (24%) were of B cell immunophenotype and 13 (25%) did not stain. The age and sex of koalas did not correlate with immunophenotype (P = 0.686 and P = 1.000, respectively). Thirty-two cases were leukaemic and 36 had multiple organ involvement, probably reflecting presentation of koalas at advanced stages of disease. Abdominal tissue involvement was most common (44 cases), followed by nodal (32), atypical (21) and cervicomediastinal (14). The T cell immunophenotype was over-represented among the leukaemic cases (P = 0.013). Generally, the T cell immunophenotype predominated except for many affected atypical tissues. Neoplastic cells were mostly of medium nuclear size with round to oval nuclei. No correlations were found for cell morphology, mitotic index and immunophenotype. CONCLUSION: The prognostic value of an immunophenotypic, anatomical and morphological basis for the classification of lymphoid neoplasia in the koala currently is limited by the need to detect these neoplasms at an early age, the requirement for freshly fixed tissues and the restricted range of available cross-reacting antibodies.     

Skeletonized right gastroepiploic artery used for coronary artery bypass grafting

The right gastroepiploic artery has been definitively recognized as a reliable conduit for coronary artery bypass grafting with excellent clinical results and midterm patency. Our experience with internal thoracic artery skeletonization and the similarities between the gastroepiploic and internal thoracic arteries prompted us to modify the gastroepiploic artery harvesting technique. The purpose of this report is to present the advantages of the skeletonized gastroepiploic artery graft.     

Reoperative coronary bypass grafting without cardiopulmonary bypass through a small thoracotomy

BACKGROUND: The danger of coronary reoperations is mainly hidden in the reopening of the sternum and in the manipulation of the heart and the old grafts. Therefore, the minimally invasive direct coronary artery bypass procedure seems an ideal technique for coronary reoperations if only the left anterior descending coronary artery needs to be revascularized and the left internal mammary artery has not been used previously. METHOD: From January 1995 until May 1996 we performed 81 minimally invasive direct coronary artery bypass procedures through a small anterolateral thoracotomy in the fifth intercostal space, anastomosing the left internal mammary artery to the left anterior descending coronary artery. Six of these 81 were reoperative minimally invasive direct coronary artery bypass procedures on patients who had previously undergone coronary grafting through a median sternotomy with a vein graft to the left anterior descending coronary artery. RESULTS: Mean operation time was 85.8 +/- 22.2 minutes. Mean length of the mammary pedicles was 13 +/- 2 cm. Mean coronary occlusion time was 9.2 +/- 3.2 minutes. Mean postoperative hospital stay was 5.7 +/- 1.2 days (range, 5 to 8 days). No mortality and no cardiac-related morbidity were recorded. CONCLUSIONS: These results suggest that the technique is safe and promising in selected cases of reoperative coronary operation.     

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.     

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.     

Minimally invasive bilateral internal mammary artery bypass grafting

A 34-year-old HIV-positive black man with pulmonary tuberculosis developed progressive widening of the mediastinum. Evaluation by CT and two-dimensional echocardiography demonstrated a large saccular aneurysm of the ascending aorta. This was repaired with a 26-mm aortic homograft using deep hypothermic circulatory arrest. The microbiology of the aneurysm contents showed this to be a tuberculous pseudoaneurysm.     

SPECT perfusion imaging after coronary artery bypass grafting

The effects of progestins on bone loss in female oophorectomized (ovx) rats were evaluated. One-year-old Sprague-Dawley rats were divided into eight groups: (1) beginning controls (control); (2) sham-operated controls (sham); (3) ovx; (4) ovx treated with estrogen (ovx + E); (5) ovx treated with progesterone (ovx + P); (6) ovx treated with estrogen and progesterone (ovx + E + P); (7) sham group treated with estrogen (sham + E); and (8) sham group treated with progesterone (sham + P). Immediately after surgery, the rats in the hormone injected groups were subcutaneously (s.c.) injected daily for 15 weeks with estrogen (17-beta-estradiol, 0.01 mg/kg in ethanol), or progesterone (4-pregnene-3,20-dione, 0.1 mg/kg in ethanol), or both. At the end of 15 weeks, the bone mineral density (BMD) and bone histomorphometry of the rats' lumbar vertebrae and serological parameters were measured. In the sham, ovx, and ovx + P groups, treatment with progesterone alone did not maintain the BMD in the lumbar vertebrae, but in the ovx + E and ovx + E + P, sham + E, and sham + P groups, progesterone did not inhibit the action of estrogen in the aged ovx rat model. BMD in the sham + P group was significantly higher than in the sham group (270.8+/-10.8 mg/cm2 versus 253.6+/-10.2 mg/cm2; p < 0.01). Bone histomorphometry revealed that bone volume (BV/TV) increased more in the ovx + E + P group than in the ovx + E group and more in the sham + P group than in the sham group, but not significantly. The ovx + E, ovx + E + P, sham + E, and sham + P groups showed no significant differences in the bone formation and resorption parameters, but the bone formation variables tended to increase in the ovx + E + P and sham + P groups. We concluded that progesterone alone cannot prevent bone loss or the increase in turnover after ovx and that estrogen, not progesterone, accounted for all of the bone activity in this study. It seems doubtful that progesterone inhibits the action of estrogen, and in fact may have a beneficial effect on bone metabolism.     

Coronary artery bypass grafting in immune thrombocytopenic purpura

BACKGROUND: Reports of patients with idiopathic thrombocytopenic purpura undergoing cardiac operations are scarce and no recommendations exist regarding their management. We report 3 patients with idiopathic thrombocytopenic purpura and severe coronary artery disease who underwent uncomplicated coronary bypass grafting. METHODS: The case history of each patient with idiopathic thrombocytopenic purpura who underwent coronary artery bypass grafting and the literature were reviewed. RESULTS: All 3 patients underwent uncomplicated coronary artery bypass grafting after preoperative treatment with intravenous immunoglobulin and intraoperative platelet transfusions if needed. Prophylactic splenectomy was not performed. There was no increased incidence of bleeding complications. CONCLUSIONS: Coronary artery bypass grafting can be safely performed in patients with idiopathic thrombocytopenic purpura using conventional conduits after pretreating with immunoglobulin G and avoiding splenectomy.     

Long-term results of emergency coronary artery bypass grafting

Growth of the thermoacidophilic Gram-positive bacterium Alicyclobacillus acidocaldarius strain ATCC 27009 on maltose resulted in the increased production of a protein with apparent molecular mass of 40 kDa. By metabolic labelling with 14C-palmitic acid, the 40-kDa protein was identified as a lipoprotein. The protein exhibited maltose-binding activity at pH 3.5, as demonstrated by chromatography on cross-linked amylose. Partial amino acid sequence analysis revealed that the 40-kDa protein corresponds to the product of an open reading frame downstream from the amylase gene (amy) that displays similarity to enterobacterial maltose-binding proteins.