Aortocoronary Artery Bypass Graft Research Articles

Aortocoronary Bypass for a Patient with Achondroplasia Using the Son's Saphenous Vein Homograft

<h3>Introduction</h3> Congenital dwarfism (achondroplasia) in severe form does not allow materials to be used as a routine aortocoronary artery bypass graft when the limb is very short. A saphenous vein homograft may be an option, but a vein graft taken from a close family member may be used. The report to introduce such a rare case at Viet Duc University Hospital, Vietnam. <h3>Case Report</h3> A case report of a man, 55 years old, severe congenital dwarfism with very short limbs, obesity, lipid metabolism disorders, stenosis - occlusion of 3 coronary arterial trunks with no indication for endovascular intervention, unstable angina, severe mitral regurgitation due to posterior ligament rupture, heart failure with an EF of about 50%. Mandatory indication for aortocoronary bypass and mitral valve repair. The patient's sternum was also deformed unfavorably to harvest the internal thoracic artery as a graft. The patient has a 25-year-old son with normal body shape and health. At Viet Duc Hospital, homograft has been used routinely, but no saphenous vein is available. <h3>Summary</h3> The procedure for organ donation was carried out in accordance with the law to use his son's saphenous vein as the main graft. Two operations were performed in parallel on November 26, 2019. The large saphenous vein in the two legs of the son was harvesting in two 20cm long segments - the operation went smoothly, and the son was awake and safe in 2 hours after surgery. Surgery for the father included two aortocoronary bypass (LAD and Cx arteries) using the son's vein, and mitral valve reconstruction with a ring. The postoperative process was quite favorable with some respiratory disorders, the endotracheal tube was removed after 3 days, the cardiac function and postoperative bypass were assessed well, the patient was discharged 17 days after surgery. The patient's son is also stable and discharged after 5 days. Periodic examination of patients in 2 years after surgery has good results. <h3>Conclusion</h3> In clinical practice, treatment solutions are very diverse and it is possible to explore and create the most reasonable solution for each specific complex situation. The case of using homograft donor tissue from a close relative, with legal procedures in accordance with the provisions of tissue-organ donation, as a material for coronary artery bypass grafting is such a situational solution.

Determination of the influence of risk factors for coronary artery disease on the effectiveness of cardiac surgery by the method of myocardial scintigraphy

Background. Myocardial revascularization is a life-saving technology that not only increases life expectancy, reduces recurrences of myocardial infarction and repeated surgery, but also improves its quality in patients with coronary artery disease. Risk assessment, the complexity of coronary artery disease, the presence of comorbidities, the area of hibernating myocardium, the patient’s consent are the basis for choosing a method of treatment. Positive structural and functional changes of the myocardium (increase in the area of viable myocardium), restoration or improvement of left ventricular systolic function (increase in ejection fraction and decrease in end-diastolic volume), reduction of angina are the expected result of the surgical treatment. Purpose – determining the influence of risk factors for coronary heart disease on the outcome of surgical treatment by aorto-coronary artery bypass grafting with the help of diagnostic evaluation of myocardial scintigraphy. Materials and Methods. To achieve the clinical tasks, 62 patients with coronary artery disease were examined. The mean age of the subjects was (59.6 ± 8.2) years. Myocardial scintigraphy was performed in SPECT with ECG synchronization (Gated SPECT). 99mTc-MIBI with an activity of 555–740 MBq was used. Myocardial scintigraphy was performed over time of treatment (before and after coronary artery bypass grafting) according to the protocol – One Day Rest. Results. The influence of risk factors was assessed using dynamic and static integrated indicators. The dynamic integral indicator did not show statistically significant risk factors: smoking (p = 0.54), left ventricular contractility (p = 0.43), the presence of myocardial infarction in past (p = 0.4), heart failure stage (p = 0.53) and functional class of angina (p = 0.08). The static integrated indicator also did not show statistically significant effects from smoking (p = 0.13), left ventricular contractility (p = 0.58), the presence of myocardial infarction in past (p = 0.1), heart failure stage (p = 0.11) and functional class of angina (p = 0.6). Conclusions. The risk factors for coronary artery disease, such as: myocardial infarction in past, left ventricular contractility, heart failure stage, functional class of angina and smoking, in the study group of patients, had no reported effect on revascularization by the method of aorto-coronary artery bypass grafting (static and dynamic integrated indicators p &gt; 0.05).

Role and place of radiotherapy in neoadjuvant treatment of pancreatic cancer

Background. Myocardial revascularization is a life-saving technology, which contributes to increase in lifespan, reduction in myocardial infarction recurrences and repeated surgeries along with improved life quality of the patients with coronary artery disease (CAD). Estimation of the risks, severity of coronary bed lesion, presence of concomitant diseases, and area of hibernating myocardium, as well as patient’s agreement are the basis of treatment method selection. Positive structural and functional changes in myocardium (increase in area of viable myocardium), restoration or improvement of systolic function of left ventricle (increase in ejection fraction and decrease in end-diastolic volume), reduction of angina symptoms are the expected results from the surgical treatment.&#x0D; Purpose – to determine the influence of risk factors for coronary artery disease on the outcome of surgical treatment by the method of aorto-coronary artery bypass grafting with the help of diagnostic evaluation of myocardial scintigraphy parameters.&#x0D; Materials and methods. For the implementation of the clinical objectives, 62 patients with coronary artery disease were examined. The average age of the patients was 59.6 ± 8.2 years. Myocardial scintigraphy was performed in the SPECT mode with ECG synchronization (Gated SPECT). 99mTc-MIBI with an activity of 555-740 MBq was used. Myocardial scintigraphy was conducted over time of treatment (before and after coronary artery bypass grafting) according to One Day Rest protocol.&#x0D; Results. The influence of risk factors was assessed using dynamic and static integral indices. The dynamic integral index didn’t reveal statistically significant risk factors: smoking (p = 0.54), left ventricular contractility impairment (p = 0.43), history of myocardial infarction (p = 0.4), stage of heart failure (p = 0.53), and functional class of angina (p = 0.08). The static integral index didn’t reveal statistically significant influence as well: smoking (p = 0.13), left ventricular contractility impairment (p = 0.58), history of myocardial infarction (p = 0.1), stage of heart failure (p = 0.11), and functional class of angina (p = 0.6).&#x0D; Conclusions. The studied risk factors for coronary artery disease, namely: history of myocardial infarction, left ventricular contractility impairment, stage of heart failure, functional class of angina, and smoking in the study group of patients had no registered influence on the revascularization effect by coronary artery bypass grafting method (integrated static and dynamic indices p &gt; 0.05).

Chylothorax After Cardiac Surgery

Abstract In the following article we present a case of postoperative chylothorax as rare and severe complication after cardiac surgery. We present a case of 56-year-old man after double-valve replacement procedure and aorto-coronary artery bypass grafting, including pedicled left internal mammary artery towards left anterior descending artery. By the tenth postoperative day the total amount of drained milky white fluid from the left pleural cavity reached the colossal volume of 13 040 ml, despite the conservative therapy with intravenous Sandostatin (Octreotide) and parenteral feeding with a solution rich in medium chain triglycerides and amino acids – OliClínomel. The results of the biochemical analysis confirmed the diagnosis chylothorax. On the tenth postoperative day, a revision of the left pleural cavity through left thoracotomy was performed and lesion of the thoracic duct was identified. The lesion was sutured and secured with fibrin tissue glue – Tissucol for definitive treatment of the lymphorrhagia. The combined therapeutic and surgical approach concerning this serious complication turned out to be effective, and the patient was discharged on the thirty-second postoperative day with significant clinical improvement without ultra-sound and x-ray data for left pleural effusion.

Maximal blood flow acceleration analysis in the early diastolic phase for aortocoronary artery bypass grafts: a new transit-time flow measurement predictor of graft failure following coronary artery bypass grafting.

Maximal graft flow acceleration (max df/dt) determined using transit-time flowmetry (TTFM) in the diastolic phase was assessed as a potential predictor of graft failure for aortocoronary artery (AC) bypass grafts in coronary artery bypass patients. Max df/dt was retrospectively measured in 114 aortocoronary artery bypass grafts. TTFM data were fitted to a 9-polynomial curve, which was derived from the first-derivative curve, to measure max df/dt (9-polynomial max df/dt). Abnormal TTFM was defined as a mean flow of <15ml/min, a pulsatility index of >5 or a diastolic filling ratio of <50%. Postoperative assessments were routinely performed by coronary artery angiography (CAG) at 1year after surgery. Using TTFM, 68 grafts were normal, 4 of which were failing on CAG, and 46 grafts were abnormal, 21 of which were failing on CAG. 9-polynomial max df/dt was significantly lower in abnormal TTFM/failing by the CAG group compared with abnormal TTFM/patent by the CAG group (1.08±0.89 vs. 2.05±1.51ml/s(2), respectively; P<0.01, Mann-Whitney U test, Holm adjustment). TTFM 9-polynomial max df/dt in the early diastolic phase may be a promising predictor of future graft failure for AC bypass grafts, particularly in abnormal TTFM grafts.

On-Pump Beating Heart Surgery Offers an Alternative for Unstable Patients Undergoing Coronary Artery Bypass Grafting

Abstract Background: Cardiac surgery has expanded the available approaches to aortocoronary artery bypass grafting to include approaches from minimally invasive surgery to full sternotomy. The heart can be arrested, left beating, or assisted with a right ventricular assist device or cardiopulmonary bypass pump. We have examined the 4 surgical modes that we use routinely in our large multisurgeon practice to determine our selection biases and the outcomes of the different techniques. Methods: Of the 4733 coronary artery bypass grafting (CABG) patients we studied from January 2000 through December 2002, 2332 (49.3%) operations were done on-pump on the arrested heart, 1908 (40.3%) were performed off-pump, 364 (7.7%) were performed on-pump on the beating heart, and 129 (2.7%) were performed with right heart assist. The preoperative risk factors, operative variables, and postoperative outcomes of the groups were analyzed. Results: Patients selected for on-pump beating heart procedures tended to be sicker with the highest predicted risk of death. We also selected patients who were in cardiogenic shock, in resuscitation, in emergent or salvage status, on dialysis, and with preoperative intra-aortic balloon pump (IABP) use for on-pump beating heart procedures at higher than expected rates. Patients with renal failure with or without dialysis, and those having a history of cerebrovascular accident tended not to be chosen for on-pump arrested heart procedures. Off-pump beating heart procedures were avoided for patients with cardiogenic shock or resuscitation, in emergent or salvage status, and with preoperative IABP use. The mortality rate in these patients was slightly worse in the on-pump beating heart group (4.4%) than in the on-pump arrested heart (3.5%) and off-pump (2.3%) groups (analysis of variance [ANOVA], P =.04). Atrial fibrillation occurred more frequently in both the on-pump beating heart (20.1%) and on-pump arrested heart (23.8%) groups (ANOVA, P <.001). The on-pump groups had higher rates of blood product use and reoperation for bleeding and a prolonged ventilation rate, compared with the other procedures. On-pump patients had a statistically longer length of stay than either off-pump or right heart-assisted patients ( P <.05) and required longer times on the ventilator and in the intensive care unit. Conclusions: Normothermic cardiopulmonary bypass with a beating heart is safe and efficacious and may be the method of choice for patients in cardiogenic shock, requiring resuscitation, or with previous CABG surgery, recent myocardial infarction, a low ejection fraction, or unstable arrhythmias.

Investigation of aortocoronary artery bypass grafts by multislice spiral computed tomography with electrocardiographic-gated image reconstruction

X-ray coronary angiography, the reference standard for investigation of coronary artery bypass grafts, is an invasive and costly procedure that is not risk free. The development of rapid and reliable noninvasive imaging procedures would therefore be desirable. Evaluation of coronary bypass patients with computed tomography (CT) was first reported in 1980. 1 Brundage B.H. Lipton M.J. Herfkens R.J. Berninger W.H. Redington R.W. Chatterjee K. Carlsson E. Non-invasive assessment of coronary artery bypass grafts by computed tomography. A preliminary report. Circulation. 1980; 61: 826-831 Crossref PubMed Scopus (99) Google Scholar In the following years, a number of studies described the application of conventional CT and electron beam tomography for investigation of bypass grafts. 2 Kahl F.R. Wolfman N.T. Watts L.E. Evaluation of aortocoronary bypass graft status by computed tomography. Am J Cardiol. 1980; 48: 304-310 Abstract Full Text PDF Scopus (15) Google Scholar , 3 McCay C.R. Brundage B.H. Ullyot D.J. Turley K. Lipton M.J. Ebert P.A. Evaluation of early postoperative coronary artery bypass graft patency by contrast-enhanced computed tomography. J Am Coll Cardiol. 1980; 2: 312-317 Abstract Full Text PDF Scopus (34) Google Scholar , 4 Foster C.J. Sekiya T. Brownlee W.C. Isherwood I. Computed tomographic assessment of coronary artery bypass grafts. Br Heart J. 1980; 52: 24-29 Crossref Scopus (11) Google Scholar , 5 Daniel W.G. Döhring W. Stender H.S. Lichtlen P.R. Value and limitations of computed tomography in assessing aortocoronary bypass graft patency. Circulation. 1980; 67: 826-831 Google Scholar , 6 Tello R. Costello P. Ecker C. Hartnell G. Spiral CT evaluation of coronary artery bypass graft patency. J Comput Assist Tomogr. 1980; 17: 253-259 Crossref Scopus (59) Google Scholar , 7 Engelmann M.G. von Smekal A. Knez A. Kürzinger E. Huehns T.Y. Höfling B. Reiser M.F. Accuracy of spiral computed tomography for identifying arterial and venous coronary graft patency. Am J Cardiol. 1980; 80: 569-574 Abstract Full Text Full Text PDF Scopus (55) Google Scholar , 8 Stanford W. Brundage B.H. MacMillan R. Chomka E.V. Bateman T.M. Eldridge W.J. Lipton M.J. White C.W. Wilson R.F. Johnson M.R. Marcus M.L. Sensitivity and specificity of assessing coronary bypass graft patency with ultrafast computed tomography Results of a multicenter study. J Am Coll Cardiol. 1980; 12: 1-7 Abstract Full Text PDF Scopus (82) Google Scholar , 9 Knez A. von Smekal A. Haberl R. Spiegl F. Reichart B. Reiser M.F. Steinbeck G. Significance of ultrafast computed tomography in the assessment of coronary bypass graft patency. Z Kardiol. 1980; 85: 629-634 Google Scholar , 10 Achenbach S. Moshage W. Ropers D. Nossen J. Bachmann K. Noninvasive, three-dimensional visualization of coronary artery bypass grafts by electron beam tomography. Am J Cardiol. 1980; 79: 856-861 Abstract Full Text Full Text PDF Scopus (122) Google Scholar However, due to cardiac and respiration artifacts, conventional CT was restricted to assessment of bypass graft patency and the detection of stenoses in patent bypass grafts was not considered possible. Electron beam tomography is not widely available. Recently, contrast-enhanced multislice spiral CT (MSCT) with retrospective electrocardiographic gating has been shown to permit visualization of the coronary artery lumen. 11 Ohnesorge B. Flohr T. Becker C. Kopp A.F. Schoepf U.J. Baum U. Knez A. Klingenbeck-Regn K. Reisser M.F. Cardiac imaging by means of electrocardiographically gated multisection spiral CT Initial experience. Radiology. 1980; 217: 564-571 Crossref Scopus (454) Google Scholar , 12 Achenbach S. Ulzheimer S. Baum U. Kachelriess M. Ropers D. Giesler T. Bautz W. Daniel W.G. Kalender W.A. Moshage W. Noninvasive coronary angiography by retrospectively ECG-gated multislice spiral CT. Circulation. 1980; 102: 2823-2828 Crossref Scopus (438) Google Scholar We therefore performed a prospective comparison of MSCT to invasive coronary angiography in a group of 65 patients after coronary artery bypass surgery to evaluate the method’s accuracy to detect bypass graft occlusion and stenosis.

RETRACTED: Prophylactic use of pentoxifylline on inflammation in elderly cardiac surgery patients

Inflammation plays a pivotal role in the pathogenesis of organ injury after cardiopulmonary bypass (CPB). Elderly patients appear to be especially prone to develop general inflammation. Use of pentoxifylline (PTX) before surgery may be a promising approach to minimize the negative effects of CPB in these patients. In a prospective, randomized study, patients more than 80 years old undergoing aortocoronary artery bypass grafting received either PTX (n = 15) after induction of anesthesia (initial bolus of 300 mg followed by a continuous infusion of 1.5 mg.kg(-1).h(-1) during the next 2 days) or saline as placebo (control group; n = 15). Polymorphonuclear neutrophil (PMN) elastase, C-reactive protein (CRP), and interleukins (IL-6, IL-8, IL-10) were measured from arterial blood samples before surgery (T0), at the end of surgery (T1), 5 hours after surgery (T2), and at the morning of the first (T3) and second (T4) postoperative day. Postoperatively, PTX-treated patients less often needed catecholamines and were extubated earlier than the control patients (p < 0.05). On the intensive care unit, cardiac index inceased more in the PTX-treated (from 1.95 +/- 0.3 to 3.26 +/- 0.4 L.min(-1).m(-2)) than in the control patients (from 1.89 +/- 0.2 to 2.78 +/- 0.3 L.min(-1).m(-2)). Increase in CRP and PMN-elastase was significantly higher in the untreated control than in the PTX patients. After CPB, IL-6, IL-8, and IL-10 increased in both groups showing a significantly higher increase in the untreated control patients (IL-8 control: from 11.3 +/- 2.6 to 154.4 +/- 57 pg/mL [T1]); IL-8 PTX: from 10.9 +/- 2.7 to 71.8 +/- 23 pg/mL [T1]). In elderly cardiac surgery patients, use of PTX before surgery and continued after CPB resulted in less inflammatory response than in an untreated control group. The value of attenuating the inflammatory process by PTX on outcome in this patient population needs to be evaluated in further controlled studies.

Noninvasive, Three-Dimensional Visualization of Coronary Artery Bypass Grafts by Electron Beam Tomography

Electron beam tomography (EBT, ultrafast computed tomography [CT], cine CT) combines unique temporal and high spatial resolution and is especially well suited for cardiac imaging. We established and evaluated a protocol for the noninvasive visualization and assessment of aortocoronary artery bypass grafts. Twenty-five patients with 56 bypass grafts were studied by EBT. Forty contiguous cross-sectional images were acquired triggered to the electrocardiogram during breathhold and intravenous injection of contrast agent. Three-dimensional reconstructions of the heart and bypass grafts were performed and compared with selective angiography of the bypass grafts. In 1 patient with 2 bypass grafts, a technically inadequate EBT examination was obtained. In the remaining patients (54 grafts), all 13 bypass occlusions were diagnosed with a sensitivity and specificity of 100%. Evaluation for hemodynamically relevant stenosis was possible in 84% of cases (36 of 43 patent grafts) and yielded a sensitivity of 100% (5 of 5 high-grade stenoses correctly detected) and specificity of 97% (1 false-positive diagnosis of high-grade graft stenosis). The main reasons for impaired ability to evaluate the scans were breathing artifacts and misplacement of the imaging volume, causing parts of the bypass grafts to be cut off. EBT permits noninvasive determination of bypass graft occlusion and relevant stenosis with high accuracy.The value of contrast-enhanced electron beam tomography (EBT) and 3-dimensional reconstruction for the detection of bypass graft occlusion and stenosis was assessed in 25 patients. Compared with invasive angiography in a blinded fashion, EBT permitted the detection of bypass graft occlusion with 100% accuracy (13 of 13) and visualization of high-grade stenoses with a sensitivity of 100% (5 of 5) and specificity of 97%.

Evaluation of laboratory coagulation and lytic parameters resulting from autologous whole blood transfusion during primary aortocoronary artery bypass grafting

Study Objective: To determine if autologous blood reinfusion influences overall hemostatic function following aortocoronary artery bypass graft (CABG) surgery, and if so, where the predominant area of this influence lies. Design: Prospective, with control values on each patient. Setting: Cardiac operating room of a major university-affiliated county hospital. Patients: 20 patients undergoing elective CABG surgery. Interventions: Following heparinization, and prior to cardiopulmonary bypass (CPB), venous blood (average 4.9 ml/kg) was removed via an indwelling internal jugular catheter into a preservative-free plastic transfer pack unit and stored without agitation at room temperature. This autologous whole blood was reinfused after systemic protamine reversal of heparin. Blood samples for analysis were drawn immediately before and 5 minutes after completion of the reinfusion. Measurements and Main Results: Autologous blood reinfusion appears to be significantly related to increased hemoglobin, hematocrit, platelet count, fibrinogen, plasminogen, and antiplasmin levels. The prothrombin time and activated partial thromboplastin times decreased significantly, whereas activated clotting times and D-dimer levels were unchanged. Significant increases occurred in the following thromboelastography parameters: maximum amplitude, amplitude 60 minutes after the maximum amplitude, and whole blood clot lysis index. Reaction time and coagulation time were not statistically different from control values. Conclusions: Significant improvements in coagulation and lytic parameters occur following CPB after the infusion of autologous blood. These improvements in coagulation indices may be the result of the infused blood or hemoconcentration, which is also known to occur during this period. Additional control studies are needed to differentiate these effects.

Endocrine responses to total intravenous anesthesia with droperidol, fentanyl, and ketamine in cardiac patients.

Ketamine-induced sympathetic stimulation can be inhibited by administration of sedatives such as benzodiazepines, droperidol, or opioids. We have developed total intravenous anesthesia with ketamine in combination with droperidol and fentanyl (DFK) and have used this anesthetic method in more than 4000 surgical cases. In this study, we compared DFK in cardiac surgery with isoflurane-fentanyl anesthesia (AOI-F). Fourteen patients undergoing aortocoronary artery bypass graft surgery were randomly assigned to the DFK or AOI-F groups. The endocrine responses of the patients were evaluated from the plasma, levels of cortisol, antidiuretic hormone (ADH), atrial natriuretic peptide (ANP), and aldosterone. In both groups, anesthesia per se did not induced any significant changes in the hormones. Although cortisol and ADH increased during surgery, ANP and aldosterone did not change appreciably. All hormones were significantly elevated after the end of cardiopulmonary bypass. There were no significant differences in any of the hormones, blood pressure, and heart rate measured at different points in both groups. These results showed that DFK anesthesia as a total intravenous anesthesia deserves to be studied in more depth.

Thrombotic Obstruction of the Right Coronary Artery in a Postoperative Patient with Bland-White-Garland Syndrome.

A 53-year-old female presented with symptoms of severe chest and back pain associated with oliguria. The patient had a history of exertional dyspnea since the age of 20, and easy fatigability since the age of 27. At the age of 41, she noted marked exacerbation of these symptoms after suffering from a cold and was ultimately diagnosed as having Bland-White-Garland (BWG) syndrome with mitral valve regurgitation. The patient then underwent re-implantation of an anomalous left coronary artery from the pulmonary artery to the posterolateral wall of the aorta. Eleven years later, she re-presented with symptoms of angina and congestive heart failure. Coronary angiography was subsequently performed and a total occlusion of the right coronary artery with probable thrombus was revealed. The right coronary artery was filled via collaterals from the implanted left coronary artery. Mitral regurgitation was noted during angiography. The patient underwent aorto-coronary artery bypass grafting of the right coronary artery and concomitant mitral valve replacement. Her postoperative condition remained excellent.

Prophylactic Myocardial Revascularization Based on Dipyridamole-Thallium Scanning before Peripheral Vascular Surgery

Cardiac events continue to be the leading cause of perioperative mortality following peripheral vascular reconstruction. The role of preoperative cardiac screening and prophylactic myocardial revascularization in patients without clinical evidence of coronary artery disease is undefined. Fifteen patients with no clinical evidence of coronary artery disease who were found to have reversible defects on dipyridamole-thallium scans and severe correctable coronary artery disease underwent aortocoronary artery bypass grafting. There was one (6.7%) operative death. Three patients (20%) developed postoperative complications: two atrial fibrillation and one breakdown of the saphenous vein harvest site. Thirteen patients underwent subsequent peripheral vascular surgery: seven had abdominal aortic procedures, three infrainguinal reconstruction, two carotid endarterectomy and one carotid-subclavian artery bypass. There were no perioperative or late deaths, cardiac complication, electrocardiographic changes, or episodes of angina associated with the peripheral vascular procedures. Thus, dipyridamole-thallium imaging appears to help select a group of symptom-free, but high cardiac risk, vascular patients in whom preparatory myocardial revascularization and subsequent peripheral vascular surgery can be performed with acceptable mortality and morbidity. The life expectancy of these patients may be improved and, specifically, the risk of their subsequent vascular surgery may be reduced by this approach.

Twenty-Year follow-up of saphenous vein aortocoronary artery bypass grafting

The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Fortyeight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, 10-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant relationships between the length of survival and sex, the number of grafts received, or the presence of left main stenosis. Survival was inversely related to age at initial operation ( p = 0.046) as well as initial left ventricular end-diastolic pressure ( p = 0.033). Survival positively correlated with the occurrence of triple-vessel disease ( p = 0.031) and the presence of diffuse disease ( p = 0.0077). Survival correlated with the occurrence of repeat grafting ( p = 0.0079), the interval to repeat grafting ( p = 0.0001), and survival after repeat grafting ( p = 0.030), but again did not correlate with the operation received. The 5- and 10-year survival rates for repeat operation were 77.4% and 71.0%, respectively. Saphenous vein coronary artery bypass grafting in this era yielded a 41% 20-year survival. Cardiac-related events continued to account for the majority of all late deaths. Thirty-six percent of all patients and 53% of all long-term survivors underwent repeat operation. Repeat operation significantly influenced long-term survival.

Ventricular reconstruction with vascular prosthesis after aneurysmectomy: Ability to defibrillate and utilize the internal cardioverter defibrillator

Adjunct surgical procedures for patients with malignant ventricular tachyarrhythmias who require the automatic internal cardioverter defibrillator include aortocoronary artery bypass graft surgery, valvular repair or replacement, subendocardial resection, and aneurysmectomy. Ventricular reconstruction and its compatibility with the AICD are described in a 64-year-old man who required treatment of refractory ventricular tachycardia as well as resection of a large anteroapical aneurysm. Reconstruction using a dacron patch preserved left ventricular geometry but did not adversely affect the ability to defibrillate and allowed successful utilization of the automatic defibrillator.

The effect of histamine-receptor blockade on the hemodynamic responses to protamine

A prospective randomized study was undertaken to evaluate the use of histamine-receptor blockade to prevent protamine-induced hypotension in patients undergoing elective aortocoronary artery bypass graft surgery. Normotensive patients with good left ventricular function who did not receive vasoactive or inotropic agents after cardiopulmonary bypass (CPB) were allocated to either a study or a control group. After CPB, patients in the study group received 10 mg of chlorpheniramine, and 400 mg of cimetidine, intravenously, five minutes before infusion of protamine. In both groups, protamine was injected via a central venous cannula at 2.5 mg/sec. Hypotension in the control group was significantly more severe and prolonged than in the study group. Systolic and mean arterial blood pressures in the control group fell 35% and 34%, differing significantly ( P < 0.01) from the study group in whom the reduction was 24% for both systolic and mean pressures. In addition, the control group showed significant falls in central venous pressure and increases in heart rate following protamine. In conclusion, it appears that the hemodynamic changes are only partially mediated through histamine action, and the normal response to protamine may be modified, but not abolished, by H 1 and H 2 receptor blockade. This blockade may, however, prevent the reduction in right heart preload and increase in heart rate following protamine.

Post-operative respiratory failure due to bilateral phrenic nerve palsy

A 65 year old female patient developed a large left pleural effusion and a sternal split dehiscence following aorto-coronary artery bypass grafting. A second operation was performed to investigate and drain the pleural effusion and to repair the sternum. Subsequent to this operation the patient was in acute respiratory failure due to bilateral phrenic palsy. It is probable that the left phrenic nerve was damaged in the initial operation and the right nerve in the second. The patient's subsequent progress is described.

Pregnancy in a patient with a history of myocardial infarction and coronary artery bypass grafting

A 37-year-old woman conceived after experiencing a myocardial infarction and undergoing three-vessel aortocoronary artery bypass grafting. Pregnancy was complicated by angina, which was successfully treated with propranolol and bed rest. At term the patient underwent vaginal delivery, without evidence of intrapartum myocardial ischemia or fallure.

Perioperative antithrombotic therapy for aortocoronary artery bypass graft operations

Perioperative antithrombotic therapy for aortocoronary artery bypass graft operations

Inflammatory Abdominal Aortic Aneurysm Infected by Campylobacter fetus

THE ORGANISM<i>Campylobacter fetus</i>exhibits a peculiar propensity to infect vascular endothelium.<i>Campylobacter</i>endocarditis and septic thrombophlebitis have already been seen,^1-3as has the secondary infection of a femoral artery aneurysm.⁴However, until now, diagnoses of<i>Campylobacter</i>infections in abdominal aortic aneurysms have only been made at autopsy.⁵One additional fatal case has been documented by the Centers for Disease Control, Atlanta, but the case report has not yet been published. This article demonstrates that inflammatory variant abdominal aortic aneurysms can be culture-positive—a fact hitherto unrecognized, although many physicians have tried to grow organisms from aneurysm cultures^6,7and that<i>Campylobacter</i>aortic infection can be successfully treated by a one-stage surgical repair combined with administration of antibiotics. <h3>Report of a Case</h3> A 54-year-old man had excruciating back pain and fever. Eighteen days earlier he had undergone uneventful quintuple aortocoronary artery bypass grafting for unstable angina pectoris and