History Of Coronary Artery Bypass Grafting Research Articles

Contemporary Analysis of Predictors and Etiology of Ventricular Fibrillation During Diagnostic Coronary Angiography

To assess the incidence, investigate the predictors and analyze the causes of ventricular fibrillation (VF) during coronary angiography (CA) on the condition of current techniques. From April 2004 to January 2007, a total 22,254 patients (27,798 procedures) received CA procedures in our center; 27 patients developed VF during CA. This report was to retrospectively analyze the clinical basic characteristics, coronary angiographic characteristics and CA procedure records of these patients. The incidence of VF during CA was 0.097%. The incidence of VF in radial approaches and femoral approaches was 0.076% and 0.147% (p = 0.085). The VF patients had higher coronary artery bypass grafting (CABG) rates (11.1% vs 2.3%, p = 0.024) and were more likely to have a three-vessel disease (59.3% vs 31.2%, p = 0.002) and a total occlusion lesion (25.9% vs 11.1%, p = 0.014) than non-VF patients. On logistic regression analysis, three-vessel disease (OR: 2.582, 95% CI: 1.165-5.720, p = 0.019) and the history of CABG (OR: 3.959, 95% CI: 1.160-13.513, p = 0.028) were the two independent predictors of VF occurrences. Among 27 episodes of VF, 13 were ischemia-related; 11 were manipulation-related; two were contrast-related; one was hypokalemia-related; and the causes remain unclear in five episodes. The incidence of VF during CA is low on the condition of current techniques. The severity of coronary artery disease (CAD) is an independent predictor of VF occurrence during CA. Acute ischemia and inappropriate manipulation may be the two main causes in VF development.

A large saphenous vein graft aneurysm one year after coronary artery bypass graft surgery presenting as a left lung mass

Aneurysm of a saphenous vein graft (SVG) is a rare but fatal complication of coronary artery bypass graft (CABG) surgery. The development of SVG aneurysms appears usually about 10-20 years after the operation at an estimated rate of <1%. A 68-year-old male was referred to the emergency department after frequent episodes of dyspnea, chest pain and hemoptysis. He previously had CABG surgery one year before. The physical examination was normal. Chest radiogram showed a left pulmonary midzone mass. CT-angiogram demonstrated a large aortic pseudoaneurysm (6.36 x 6.06 cm) in the middle part of the ascending aorta. After sternotomy, the ascending aorta above sinotubular junction near the origin of brachiocephalic artery was resected and replaced with a tube graft. The patient was transferred to ICU with stable hemodynamic status. SVG aneurysm should be considered while encountering mediastinal mass or undiagnosed cardiopulmonary symptoms in patients with a previous history of CABG because of its rarity and overlap of symptoms with other thoracic, pulmonary, and cardiac diseases. Surgery seems to be the treatment of choice to reduce the risk of rupture and embolism.

Perioperative antiplatelet therapy in patients at risk for coronary stent thrombosis undergoing noncardiac surgery

Sirs:Premature discontinuation of antiplatelet therapy is themost important predictor of thrombotic events after coro-nary stent implantation [5]. However, noncardiac surgeryoften requires the interruption of the standard dual-anti-platelet therapy using aspirin (75–100 mg/day) andclopidogrel (75 mg/day). Even though the problem for theperioperative management of these particular high-riskpatients has been addressed in guidelines, no clear rec-ommendation for high-risk patients is given in thoseguidelines [3, 10].Here we report on seven patients at high-risk for bothperioperative bleeding and stent thrombosis, respectively.In these patients the peri- and postoperative time interval ofthe interruption of dual-oral-antiplatelet therapy has beenbridged by using a short-acting intravenous GPIIb–IIIa-inhibitor. The demographic details are shown in Table 1.A3-month follow-up has been performed by telephoneinterview.Patient 1, a 71-year-old man, presented with a tibialimpression fracture after a car accident. He had a history ofcoronary artery bypass graft surgery plus a thrombarterec-tomyoftheleftcarotidarteryin2000.Whenhewasadmittedto the hospital for surgical tibial fracture realignment, thepatient developed an acute coronary syndrome (ACS). TheECGshowed anatrialfibrillation of90beatsperminutewithsignsofaformer inferiorwall myocardialinfarction(Qwave

Treatment of unprotected left main disease with drug-eluting stents in patients at high risk for coronary artery bypass grafting

Percutaneous coronary intervention (PCI) for high-grade stenosis of the left main coronary artery with bare-metal stents has been limited by restenosis, and most patients are managed with coronary artery bypass grafting (CABG). Recently, drug-eluting stents (DES) have reduced instent restenosis after PCI, but their role in the treatment of left main disease remains unclear. The aim of this study was to determine the outcomes after utilizing DES to treat left main disease. Twenty consecutive symptomatic patients with >50% angiographic stenosis of the left main coronary artery with no prior history of CABG ["unprotected left main" (ULM)] underwent PCI with DES. Patients were divided into two groups based on the presence (Group A, n=5) or absence (Group B, n=15) of preprocedural cardiogenic shock. At follow up (median, 14 months), cumulative major adverse cardiac events (MACE-death, myocardial infarction, or target vessel revascularization) were determined. Sixteen (80%) of 20 patients were at high risk for CABG because of comorbidity, advanced age, or cardiogenic shock. Procedural success was 100% (20/20). Three of five patients in Group A (60%) died in hospital and the two surviving patients experienced no MACE at follow up. In Group B (n=15), there was no in-hospital MACE, but one patient died suddenly 8 weeks postprocedure [cumulative MACE of 7% (1/15)]. Our study demonstrates the feasibility of ULM treatment with DES with acceptable medium-term outcomes. While CABG remains the best form of revascularization for the majority of patients with ULM, DES should be considered in those who are at high risk.

Clinical Predictors of Appropriate Implantable‐Cardioverter Defibrillator Discharge

The implantable cardioverter-defibrillator (ICD) is the mainstay of treatment for ventricular tachyarrhythmias due to its impact on mortality. ICD discharges may be appropriate or inappropriate, and identification of patients at risk for ICD discharge is essential. We sought to determine the predictors of appropriate ICD discharge. We analyzed data from 591 ICD recipients (mean age 67.9 +/- 13.0 years; 474 men; mean follow-up 10.9 +/- 13.8 months). The association between ICD discharges and multiple clinical variables, including age, gender, hypertension, diabetes, coronary artery bypass graft (CABG) surgery, syncope, atrial fibrillation (AF), prior coronary intervention, left ventricular ejection fraction (LVEF), left ventricular end diastolic dimension, left ventricular end systolic dimension (LVESD), and ambient drug therapy was examined. The rates of appropriate or inappropriate discharges, delivered to 155 patients, were 0.49 per follow-up year (F/Y). The median time-to-first appropriate discharge was 3.4 years. Among the discharges delivered, 97(63%) were appropriate and 58(37%) were inappropriate. Risk factors associated with a trend toward earlier appropriate discharges included age </= 65 years, and diuretic and digitalis use. By multiple variable analysis, no history of CABG and an enlarged LVESD were independent predictors of earlier appropriate ICD discharge. Patients who did not have CABG revascularization were 2.8-fold more likely than those who underwent CABG, and patients with enlarged LVESD were 2.5-fold more likely than those with normal LVESD to receive appropriate ICD discharges. These patients deserve special vigilance and management in order to prevent the occurrence of ventricular tachyarrhythmias triggering ICD discharges.

Should we continue to use BMI as a cardiovascular risk factor?

In today's Lancet, Abel Romero-Corral and colleagues 1 Romero-Corral A Montori VM Somers VK et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet. 2006; 368: 666-678 Summary Full Text Full Text PDF PubMed Scopus (1157) Google Scholar report a comprehensive systematic review and meta-analysis, of all available cohort studies examining the association between bodyweight and total mortality, cardiovascular mortality, and other cardiovascular events, including over 250 000 patients with established coronary-artery disease. Romero-Corral and colleagues used body-mass index (BMI) for analyses because it was the most common surrogate measure of obesity reported in the studies. Their results are interesting in several ways, because the meta-analysis includes 40 prospective studies with conflicting results. For patients with established coronary-artery disease, with a mean follow-up period of 3·8 years, low BMI was strongly associated with increased long-term risk of death and cardiovascular events relative to normal weight. Overweight patients were consistently associated with a better survival and fewer cardiovascular events than normal BMI patients. Obesity was associated with an increased total mortality only in patients with a history of coronary-artery bypass graft, and severe obesity was associated with the highest cardiovascular mortality but not with increased total mortality. The better outcomes in the overweight and mildly obese groups as compared with other weight categories could not be explained by adjustment for confounding. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studiesThe better outcomes for cardiovascular and total mortality seen in the overweight and mildly obese groups could not be explained by adjustment for confounding factors. These findings could be explained by the lack of discriminatory power of BMI to differentiate between body fat and lean mass. Full-Text PDF

Outcome of acute myocardial infarction in patients with prior coronary artery bypass grafting treated with combination reduced fibrinolytic therapy and abciximab

ST-segment elevation acute myocardial infarction (AMI) in patients who have undergone previous coronary artery bypass grafting (CABG) is associated with low reperfusion rates and poor outcome after fibrinolytic therapy. The efficacy of a combination strategy (reduced fibrinolytic plus platelet glycoprotein IIb/IIIa agent) in this setting is unknown. In the Global Use of Streptokinase and TPA for Occluded coronary arteries V (GUSTO V) trial, 553 patients with a history of CABG were treated with standard-dose reteplase (n = 273), or half-dose reteplase and full-dose abciximab (n = 280) in the first 6 hours of evolving ST-segment elevation MI. Mortality at 30 days was significantly higher in patients who underwent prior CABG compared with patients with no prior CABG (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.21 to 2.24, p = 0.001). In patients who underwent prior CABG, mortality at 7 days was reduced 15% with combination therapy compared with reteplase alone, which was not statistically significant (OR 0.85, 95% CI 0.40 to 1.81, p = 0.66). Patients who underwent prior CABG treated with the combination therapy had fewer episodes of recurrent ischemia (OR 0.60, 95% CI 0.37 to 0.96, p = 0.02), high degree atrioventricular block (OR 0.17, 95% CI 0.02 to 0.82, p = 0.01), and ventricular tachycardia (OR 0.29, 95% CI 0.07 to 0.96, p = 0.04). There was a trend toward reduced urgent revascularization (OR 0.61, 95% CI 0.36 to 1.03, p = 0.06) but no significant difference in reinfarction (OR 0.61, 95% CI 0.31 to 1.52, p = 0.40). In the GUSTO V trial, patients who underwent prior CABG had significantly higher event rates compared with patients without CABG. As in the overall trial, combination therapy in patients who underwent prior CABG led to a consistent reduction in key secondary complications of AMI, including recurrent ischemia and a trend toward reduced urgent revascularization.

Exudative Effusions in Congestive Heart Failure

Pleural effusions due to congestive heart failure (CHF) typically are transudates, but an occasional patient with CHF is found to have an exudate in the absence of an apparent cause other than CHF. We sought to determine the incidence and clinical significance of such exudative effusions. Patients with CHF and effusions seen during the 7-year period from January 1994 through December 2000 were identified from their hospital discharge diagnoses and radiographs, while those who had undergone thoracentesis were identified from a review of the laboratory logs. The presenting symptoms and clinical course were determined from a review of the medical records. The effect of RBC contamination on pleural fluid lactate dehydrogenase (LDH) levels was determined by measuring the LDH activity of mock pleural fluid containing known amounts of RBC. Seven hundred seventy patients had CHF with an effusion, but only 175 patients underwent a thoracentesis. In this select group, 86 patients had transudates and 89 had exudates. A noncardiac cause for the exudate was readily identified in 59 patients by hospital discharge, and 7 more patients had an etiology found during follow-up. Eleven of the remaining 23 patients had undergone coronary artery bypass graft (CABG) surgery > or = 1 year prior to presentation, and 50% of the effusions in patients who had undergone CABG surgery were exudates. Thus, CHF-related exudates were identified in only 12 patients, and in 4 of these patients the exudates could be explained by RBC contamination of the pleural fluid. The clinical presentation of patients with CHF-associated exudates was similar to that of CHF patients with transudates. In most patients who have CHF and an exudative effusion, there is a noncardiac cause for the pleural effusion. The high frequency of exudates in patients with a history of CABG indicates a persistent impairment in lymphatic clearance from the pleural cavity. Exudative effusions due solely to CHF are rare.

PCV4: ASSESSING QUALITY OF LIFE IN PATIENTS SIX MONTHS AFTER A MYOCARDIAL INFARCTION USING THE SF-12

OBJECTIVES: To assess patients' quality of life (HQL) post-myocardial infarction and to identify related variables. METHODS: Patients admitted to the University of Michigan Medical Center with diagnosis of MI were identified consecutively and prospectively from October 1999 to May 2000. Clinical data were obtained retrospectively from medical records. Six months after discharge, patients were administered the Short Form-12 (SF-12), via telephone, to determine physical (PCS-12) and mental (MCS-12) functional status. RESULTS: Complete information was obtained from 148 patients. The mean age of patients was 64.7 years (±13.2) and 79.1% were male. The mean PCS-12 scores were 35.4 (±9.12), and the mean MCS-12 scores were 51.6 (±10.01). The median PCS-12 scores were significantly lower in patients with an ejection fraction (EF) <40% (31.9 versus 38.4 for EF340%, p = 0.02), and prior MI (31.2 versus 38.5 without a history of MI, p = 0.01), congestive heart failure (CHF) (32.6 versus 37.4 without a history of CHF, p = 0.03), renal insufficiency (27.9 versus 37.7, p = 0.003), or peripheral vascular disease (29.4 versus 38.2 without a history of PVD, p = 0.004). The median MCS-12 scores were significantly lower for patients under 65 years of age (49.6 versus 57.4 for patients 365 years of age, p = 0.001) and with a history of coronary artery bypass graft (CABG) (60.1 versus 54.7 without history of CABG, p = 0.01). There were no differences detected between gender, type of MI, diabetes, hypertension, angina, or smoking. CONCLUSIONS: HQL scores were lower for patients post-MI with various comorbidities. Physical scores were significantly lower for patients with low EFs, prior MI, or CHF. Mental scores were significantly lower for patients <65 and those not having already undergone CABG surgery. Post-MI, particular attention should be paid to these patients. Further work is needed to determine whether interventions aimed at these patients will result in improved quality of life.

Reperfusion therapy in patients with acute myocardial infarction and prior coronary artery bypass graft surgery (National Registry of Myocardial Infarction-2)

We reviewed data from the National Registry of Myocardial Infarction-2 to determine the differences in characteristics and outcomes in patients with acute myocardial infarction (AMI) who have undergone previous coronary artery bypass grafting (CABG), and those who have not, and between post-CABG patients who were treated with alteplase (recombinant tissue-type plasminogen activator [rt-PA]) and those who were treated with primary percutaneous transluminal coronary angioplasty (PTCA).Demographic, therapeutic, and outcome data from patients with AMI were collected at >1,000 hospitals in the United States in collaboration with National Registry of Myocardial Infarction-2. Of the 45,925 patients receiving reperfusion therapy, 2,544 of the 39,574 treated with rt-PA (6.4%) had a history of CABG, and 375 of the 6,351 treated with primary PTCA (5.9%) had a history of CABG. Patients with a history of CABG were older, more likely to be men, and had more comorbidities, but prior CABG was still an independent predictor of mortality after multivariate regression analysis (odds ratio 1.23; 95% confidence interval 1.05 to 1.44). Among the post-CABG patients who received rT-PA or underwent PTCA, there was no significant difference in in-hospital mortality rate or the combined end point of death and nonfatal stroke. Thus, (1) prior CABG is an independent predictor of mortality, and (2) for post-CABG patients with AMI who are not in shock and who are lytic-eligible, reperfusion therapy with rt-PA and PTCA result in similar outcomes with regard to in-hospital mortality and the combined end point of death and nonfatal stroke.

Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty

Objective: Patients with coronary artery disease (CAD) who undergo noncardiac surgery are at increased risk for perioperative myocardial infarction (PMI). Undergoing successful coronary artery bypass grafting (CABG) before such surgery has been shown to decrease perioperative cardiac morbidity and mortality. Percutaneous transluminal coronary angioplasty (PTCA) is an alternative treatment for these patients. Perioperative cardiac morbidity in patients with CAD who underwent PTCA before their vascular surgery was reviewed. Setting: A tertiary care referral center for patients with cardiovascular heart disease. Participants: Review of vascular surgery database for patients who underwent vascular surgery preceded by PTCA between 1984 and 1995. Patients were excluded if they had a history of CABG within 2 years of surgery, had PTCA more than 18 months before surgery, or had incomplete data. Measurements: Data were collected concerning cardiac history, left ventricular (LV) function, perioperative cardiac morbidity (angina, MI, congestive heart failure [CHF], and arrhythmias). Main Results: Of 194 patients who underwent aortic abdominal surgery, carotid endarterectomy (CEA), or peripheral vascular surgery preceded by PTCA, 104 (54%) had a previous MI. Twenty-six patients (13.4%) had perioperative cardiac morbidity. Only one patient had an MI (0.5%; 95% confidence interval [CI], 0.0 to 2.8), whereas one patient died of CHF followed by multisystem organ failure (0.5%). The median interval between PTCA and surgery was 11 days (interquartile range, [IQR] 3 to 49 days). Patients who developed perioperative cardiac morbidity were older than those who did not ( p = 0.02). Patients who had a history of CABG (before PTCA) had a higher incidence of postoperative angina ( p = 0.04). The degree of preoperative LV dysfunction was linearly related to the incidence of new postoperative CHF ( p = 0.01). Arrhythmias were more common in patients undergoing abdominal vascular surgery (17.9%) than in those undergoing CEA (2.5%; p = 0.03) or peripheral vascular surgery (5.2%; p = 0.02). Conclusion: High-risk cardiac patients undergoing vascular surgery who have had PTCA performed up to 18 months preoperatively have a low incidence of perioperative cardiac morbidity. Prophylactic PTCA may be beneficial in patients with CAD who are at high risk for perioperative cardiac complications.

The clinical significance of performing preoperative angiography of the internal thoracic artery in coronary artery bypass surgery.

This study was designed to clarify the clinical significance of and indications for performing preoperative internal thoracic artery (ITA) angiography in patients undergoing coronary artery bypass surgery. A total of 300 possible candidates for coronary artery bypass grafting (CABG) underwent ITA angiography during diagnostic catheterization. Semi-selective angiography of bilateral ITAs were performed by injecting contrast medium manually with a 5-F right Judkins coronary catheter. The posteroanterior view of the arteriograms was recorded on a 35-mm cine film or a cut-film. Unusual angiographic findings of the ITAs were observed in nine patients (3%). These findings included: an atrophic ITA in three patients with ipsilateral subclavian artery occlusions; enlarged ITAs giving collaterals to the lower extremities in one patient with extensive aortoiliac occlusive disease; occluded ITAs in one patient with Takayasu's arteritis and two patients with a history of CABG; and a small but nonsclerotic ITA in one patient. Atherosclerotic occlusive ITAs were found in only one patient. Thus, we concluded that routine preoperative angiography of the ITA is not necessary because it is rarely affected by atherosclerosis. However, it should be performed for any of the following reasons: a cervical or supraclavicular bruit; an upper extremity blood pressure difference of greater than 20 mmHg; an extensive aortoiliac occlusion; and certain disorders such as Takayasu's arteritis or Kawasaki disease, or a history of open heart surgery.

Outcome after acute myocardial infarction in patients with prior coronary artery bypass surgery

Little is known concerning the influence of remote prior coronary artery bypass grafting (CABG) on the outcome of patients with acute myocardial infarction (AMI). Therefore, this study evaluated 2,494 patients with AMI of whom 219 (8.8%) had a history of CABG a mean of 7.1 ± 3.7 years before the index AMI. Compared with all other patients, those with a history of CABG had an increased prevalence of a history of prior AMI (153 [70%] vs 547 [24%]), congestive heart failure (48 [22%] vs 236 [10%]), and angina pectoris (165 [75%] vs 787 [35%]), all p < 0.001. There was no difference in age, but patients with prior CABG were more often men (192 [88%] vs 1,702 [75%], p < 0.001). During the hospitalization for AMI, patients with prior CABG had more recurrent ischemic pain (100 [46%] vs 732 [32%, p < 0.001]), and more frequently developed non-Q-wave AMI (72 [33%] vs 514 [23%], p < 0.01). In-hospital mortality did not differ among patients with or without prior CABG (15 [7%] vs 195 [9%]). At hospital discharge, more patients with prior CABG had complex ventricular ectopic activity on 24-hour ambulatory electrocardiographic monitoring (48 of 74 [65%] vs 327 of 797 [41%], p < 0.0001), and radionuclide ejection fraction <0.45 (53 of 99 [54%] vs 430 of 1,024 [42%], p < 0.01). Among patients undergoing coronary angiography during the first 2 months, multivessel coronary artery disease was more prevalent among patients with prior CABG (78 of 107 [73%] vs 508 of 959 [53%], p < 0.0l). Among patients with prior CABG, 25 of 133 (19%) had all grafts occluded, whereas 40 of 133 (30%) had only minor narrowing in any graft. The proportion with totally occluded grafts increased from 7 of 61 (11%) in patients who underwent operation <7 years before their AMI to 17 of 71 (24%) in patients with prior CABG ≥7 years before the index AMI (p < 0.10). One-year cardiac mortality after hospital discharge was significantly higher in patients with prior CABG (28 of 175 [16%] vs 152 of 1,827 [8%], p < 0.01). On multivariate analysis, prior CABG was of borderline (p < 0.054) independent importance to 1-year cardiac mortality. Thus, patients with prior CABG constitute a group at high risk for death after hospital discharge for AMI. This fact exists principally because of increased severity of underlying coronary artery disease and reduced left ventricular ejection fraction.