Previous Coronary Bypass Grafting Research Articles

Comparison and implications of contemporary risk scores for predicting mortality and morbidity after surgery for active infective endocarditis

Purpose: Decision-making regarding surgery for acute bacterial endocarditis is complex given its heterogeneity and often fatal course. Few studies have investigated the utility of operative risk scores in this setting. Endocarditis-specific scores have recently been developed. We compared the prognostic utility of contemporary risk scores for mortality and morbidity for endocarditis surgery. Methods: Additive and logistic EuroSCORE I, EuroSCORE II, additive Society of Thoracic Surgeon's (STS) Endocarditis Score and additive De Feo Score were retrospectively calculated for patients undergoing surgery for endocarditis for the period 2005-2011 and their prognostic value for post-operative outcomes compared. Results: A total of 146 patients were included with an operative mortality of 6.8% and mean follow-up 4.1±2.4 years. Mean scores were additive EuroSCORE I: 8.0±2.5, logistic EuroSCORE I: 13.2±10.1%, EuroSCORE II: 9.1±9.4%, STS Score: 32.2±13.5 and De Feo Score: 14.6±9.2. Corresponding areas under curve (AUC) for operative mortality 0.653, 0.645, 0.656, 0.699 and 0.744; for composite morbidity were 0.623, 0.625, 0.720, 0.714 and 0.774; and long-term mortality 0.588, 0.579, 0.686, 0.735 and 0.751. The best tool for post-operative stroke was EuroSCORE II: AUC 0.837; and ventilation>24 hours and return to theatre were De Feo Score: AUC 0.821 and 0.712. Pre-operative inotrope or intra-aortic balloon pump treatment, previous coronary bypass grafting and dialysis were independent predictors of operative and long-term mortality. Conclusion: STS and De Feo scores were good discriminants of mortality and morbidity, suggesting that development of models specifically from endocarditis surgeries and incorporation of endocarditis variables as parameters improves the prognostic utility.

Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo‐sternotomy: A case report

An 85-year-old gentlemen with a history of previous triple vessel coronary bypass grafting presented with severe aortic stenosis and occlusion of the previous saphenous vein grafts but with patent left internal mammary artery (LIMA)-left anterior descending. The patient underwent uncomplicated repeat sternotomy and aortic valve replacement with repeated coronary bypass. On post-operative day 21 the patient was successfully resuscitated from a pulseless electrical activity (PEA) arrest, and was found to have a 1-cm pseudoaneurysm of the left internal mammary artery at the level of sternomanubrial junction with associated hemothorax. The LIMA remained patent and a pinhole source of extravasation was discovered by angiography at the aneurysmal site. The defect was successfully repaired by endovascular implant of a 3.5 mm × 12 mm Graft Master covered stent (Abbott Vascular). The patient recovered well from the procedure without further complications and was discharged after a total of 48 days of hospital stay. Our experience confirms the feasibility of repairing post-operative pseudoaneurysm in the internal mammary artery by endovascular stent grafting, thereby avoiding the risks and complications of a repeat open chest procedure.

CT angiography using dual source 64-MSCT versus catheter angiography in assessment of coronary atherosclerotic disease

We compare the coronary CTA versus catheter angiography in the assessment of coronary atherosclerosis.The study included 51 patients who were referred for coronary catheter angiography after coronary CTA. The following patients were excluded: patients with irregular heart rates, patients with previous coronary bypass grafts and those with coronary stents. Patients with a resting heart rate above 75bpm and a medical contraindication for beta blockers administration are excluded. History of contrast allergy, renal impairment and severe chest conditions are exclusion criteria. The coronary angiographic CT studies were performed using a Somatom Definition “dual source” 64 CT scanner (Siemens, medical scientific Germany). The catheter coronary angiographic studies were performed via femoral arterial puncture. The standard 15-segment model of the coronary tree was employed. Segments were classified as being normal, atherosclerotic (with no significant stenosis), stenotic (>50% luminal narrowing), occlusive or non evaluable. The results of CT angiography are compared with the gold standard catheter angiography.Results: Overall sensitivity, specificity, PPV and NPV were 93%, 92%, 92% and 93%, respectively with an overall diagnostic accuracy of 93%. The sensitivity is 84% to detect stenoses 60–70% in, 85% sensitivity with 70–80% stenoses, 96% with 80–90% stenoses and 96% with stenoses more than 90%.

Thrombus Formation on a Left Atrial Appendage Closure Device

For patients with contraindications to chronic oral anticoagulation, new therapeutic approaches have been developed.1 Transcatheter closure of the left atrial appendage (LAA) is becoming more common as an interventional therapy to prevent thromboembolic complications in patients with atrial fibrillation (AF) and contraindications to chronic oral anticoagulation. Most of the studies about this new technique demonstrated its safety as an alternative method to oral anticoagulation in this group of patients.1 One of the feared complications is thrombus formation in relation with the device. To prevent this, patients are medicated with long-term antiplatelet treatment.1 A case is reported in which a thrombus was noted on the left side of an Amplatzer Cardiac Plug by transesophageal echocardiography, and anticoagulation had to be started. A 75-year-old man with chronic AF, previous ischemic stroke, known ischemic cardiomyopathy (with previous coronary bypass grafting surgery after myocardial infarction), medicated hypertension, diabetes mellitus, and a CHADS2 score of 6 had to stop oral anticoagulation because of persistent hematuria.In March 2010, a percutaneous closure of the LAA with a 28-mm Amplatzer Cardiac Plug device was performed. The procedure to implant the device was free of complications and had no residual flow at the end. …

One-year clinical outcomes in patients with previous coronary artery bypass graft surgery treated by using percutaneous revascularization with domestically made drug-eluting stent

Objective To evaluate the immediate and 1-year outcomes of percutaneous coronary intervention (PCI) with domestically made drug-eluting stent (DES) in patients with previous coronary bypass graft surgery (post-CABG) in order to determine the relationship between related factors and major adverse cardiovascular and cerebral events (MACCE) after PCI. Methods From September 2008 to October 2009, 83 consecutive post-CABG patients had implantation of 176 domestically made DES for 126 coronary lesions. Each patient was followed up at least for 1 year after the procedure done for the evaluation of the efficacy and safety of DES implanted in post-CABG patients. Logistic regression analysis was used to determine the relationship between major factors and MACCE. Results The success rate of operation procedure was 97. 5％. MACCE occurred in 10 patients including death in 1 patient, stroke in 1 patient,myocardial infarction in 1 patient, and those were treated with repeated coronary revascularization in 8patients and target lesion revascularization (TLR) in 1 patient. Conclusions Immediate and medium-term results showed the safety and efficacy of revascularization with domestically made DES in post-CABG patients. Complete revascularization was an independent predictor of MACCE. Key words: Drug-eluting stent; Coronary artery bypass grafting; Clincal outcomes

Venous graft in-stent restanosis: diagnostic and treatment evolution

This is the case of a 77 year-old man with previous coronary by-pass grafting. After the occlusion of the saphenous vein graft to marginal branch, corrected by angioplasty and stenting with a bare metal stent (BMS), during the next 4 years he experienced multiple further episodes of in-stent restenosis of the first BMS. Angioplasty was performed each time. After 4 months since the last procedure, he had new episode of unstable angina. An EKG-gated, 64-row multislice CT (MSCT) examination was performed to evaluate the venous graft lumen, showing high-grade in-stent restenosis. Angiography confirmed the MSCT diagnosis, thus he underwent angioplasty and stenting with a drug eluting stent (DES). Thereafter, he remained stable for 4 years, when new anginal episodes led to a further coronary angiogram, showing progression of the atherosclerosic disease at the proximal and distal anastomosis of the venous graft; however, the previous implanted DES was patent. In the complex management of venous grafts restenosis, MSCT can be useful to help in detecting obstructive bypass graft disease. When revascularization is needed, DES have shown to be superior compared to BMS.

The development of door-to-angiography time in the last 14 years for patients with acute ST-elevation myocardial infarction treated with primary coronary intervention: Determinants and outcome. Results from the MITRAplus and OPTAMI registry

To examine the development of door-to-angiography time (DTA) and to evaluate the impact of door-to-angiography time in patients with ST-elevation myocardial infarction (STEMI) on hospital and one-year mortality. From 1994 to 2008, 5078 patients (pts) and known DTA with acute ST-elevation myocardial infarction were enrolled into the MITRAplus and OPTAMI registry in Germany. Our data showed a reduction of the door-to- angiography time from 80 min to 64 min in the last 14 years (P < 0.001). Over 80% of patients received an angiography less than two hours after admission. The main predictor of a shorter door-to-balloon time was a hypotension with a blood pressure lower than 100 mmHg (OR 1.46, 95%CI: 1.08-1.91). Whereas a history of prior myocardial infarction (OR 0.61, 95%CI: 0.45-0.84), a previous coronary bypass grafting (OR 0.55, 95%CI: 0.33-0.91), age older than 75 years (OR 0.78, 95%CI: 0.62-0.99) and a pre-hospital delay more than three hours (OR 0.78, 95%CI: 0.66-0.93) were independent predictors for a longer of the door-to-balloon time. In the multivariate regression analysis no influence was detected of door-to-angiography time on hospital or one-year mortality. The DTA decreased in the last 14 years and is actually very short in Germany. We indentified predictors of a longer door-to-angiography time in clinical practice. Given the overall short in-hospital delay, the observed door-to-angiography time did not have influence on hospital and mid term mortality.

The value of the ECG for decision-making at first medical contact in the patient with acute chest pain.

Background/Objectives. Rapid risk stratification of the patient with acute chest pain is essential to select the best management. We investigated the value of the ECG at first medical contact to determine size of the ischaemic myocardial area and thereby severity of risk.Methods. In 386 patients with acute chest pain, ECG findings were correlated with the coronary angiogram. Using ST-segment deviation patterns the location of the coronary culprit lesion was predicted and thereby size of the area at risk. Four groups of patients were present. Those with a narrow QRS and a total 12-lead ST-segment deviation score of >/=5 mm (group 1) or </=4 mm (group 2); a QRS width of >/=120 ms (group 3), and patients with previous coronary bypass grafting (CABG) or percutaneous coronary intervention (PCI) (group 4).Results. Correct coronary culprit lesion localisation was possible in 84% of the 185 patients in group 1, 40% of the total cohort. Accurate prediction was not possible in most patients in groups 2, 3 and 4, in spite of extensive coronary artery disease in group 3 and 4. Conclusions. Using the 12-lead ECG the size of the myocardial area at risk can be accurately predicted when the total ST-segment deviation score is >/=5 mm, allowing identification of those in need of a PCI. In most patients with bundle branch block, previous CABG or PCI, the ECG can not localise the culprit lesion. This approach simplifies and accelerates decision-making at first medical contact. (Neth Heart J 2010;18:301-6.).

Beating Heart Bentall Procedure for Late Type A Aortic Dissection in a Patient with In-Situ Bilateral Mammary Artery Bypass Grafts

We report a case of a patient who had a type A aortic dissection after previous coronary bypass grafting. The in-situ right mammary artery had been anastomosed with the left anterior descending artery, the left mammary artery had been anastomosed to the obtuse marginal, and a vein graft had been used for the right coronary artery. All grafts were patent. The patients underwent a Bentall procedure on perfused heart.

Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts

As the population ages, an increasing number of patients with patent coronary grafts will require subsequent aortic valve replacement. Major operative problems include those associated with re-entry and, in particular, damage of the patent grafts. Between January 2007 and October 2008, 10 patients who had previous coronary bypass surgery underwent aortic valve replacement through upper j-shaped mini re-sternotomy. In all patients the previous grafts were patent. The operation was performed with normothermic cardiopulmonary bypass without dissection and temporary closure of the arterial and venous coronary bypass grafts. The mean age was 73.2+/-13.6 years. The patients had a mean of 2.8+/-0.6 bypass grafts. There were no intraoperative complications due to redo ministernotomy and at no time conversion to full re-sternotomy was necessary. No damage to the previous grafts was reported and the incidence of perioperative myocardial infarction was 0%. One patient required a pacemaker implantation for atrio-ventricular block. The in-hospital mortality was 0%. Aortic valve replacement in previous coronary bypass grafting can be performed safely with a mini re-sternotomy. This approach avoids extensive dissection, decreasing the risk of injuries to heart chambers and previous patent coronary grafts with low morbidity and mortality.

Three-Dimensional Printing Creates Models for Surgical Planning of Aortic Valve Replacement After Previous Coronary Bypass Grafting

Resternotomy for aortic valve replacement in patients with previous coronary artery bypass grafting and an internal mammary artery graft may be a surgical problem. Thus, we are exploring the effect of using rapid prototyping techniques for surgical planning and intraoperative orientation during aortic valve replacement after previous coronary artery bypass grafting (CABG). As a proof of concept, we studied a patient who had undergone CABG 5 years earlier. At that time the patient received a left internal mammary artery graft to the left anterior descending artery and a venous graft to the right coronary artery. Now the patient required aortic valve replacement due to symptomatic aortic valve stenosis. The left internal mammary artery bypass and the right coronary artery bypass were patent and showed good flow in the angiography. The patient was examined by 128-slice computed tomography. The image data were visualized and reconstructed. Afterwards, a replica showing the anatomic structures was fabricated using a rapid prototyping machine. Using data derived from 128-slice computed tomography angiography linked to proprietary software, we were able to create three-dimensional reconstructions of the vascular anatomy after the previous CABG. The models were sterilized and taken to the operating theatre for orientation during the surgical procedure. Stereolithographic replicas are helpful for choosing treatment strategies in surgical planning and for intraoperative orientation during reoperations of patients with previous CABG.

Depression: a predictor of smoking relapse in a 6-month follow-up after hospitalization for acute coronary syndrome

The objective of the study was to investigate whether depression is a predictor of postdischarge smoking relapse among patients hospitalized for myocardial infarction (MI) or unstable angina (UA), in a smoke-free hospital. Current smokers with MI or UA were interviewed while hospitalized; patients classified with major depression (MD) or no humor disorder were reinterviewed 6 months post discharge to ascertain smoking status. Potential predictors of relapse (depression; stress; anxiety; heart disease risk perception; coffee and alcohol consumption; sociodemographic, clinical, and smoking habit characteristics) were compared between those with MD (n=268) and no humor disorder (n=135). Relapsers (40.4%) were more frequently and more severely depressed, had higher anxiety and lower self-efficacy scale scores, diagnosis of UA, shorter hospitalizations, started smoking younger, made fewer attempts to quit, had a consort less often, and were more frequently at the 'precontemplation' stage of change. Multivariate analysis showed relapse-positive predictors to be MD [odds ratio (OR): 2.549; 95% confidence interval (CI): 1.519-4.275] (P<0.001); 'precontemplation' stage of change (OR: 7.798; 95% CI: 2.442-24.898) (P<0.001); previous coronary bypass graft surgery (OR: 4.062; 95% CI: 1.356-12.169) (P=0.012); and previous anxiolytic use (OR: 2.365; 95% CI: 1.095-5.107) (P=0.028). Negative predictors were diagnosis of MI (OR: 0.575; 95% CI: 0.361-0.916) (P=0.019); duration of hospitalization (OR: 0.935; 95% CI: 0.898-0.973) (P=0.001); smoking onset age (OR: 0.952; 95% CI: 0.910-0.994) (P=0.028); number of attempts to quit smoking (OR: 0.808; 95% CI: 0.678-0.964) (P=0.018); and 'action' stage of change (OR: 0.065; 95% CI: 0.008-0.532) (P=0.010). Depression, no motivation, shorter hospitalization, and severity of illness contributed to postdischarge resumption of smoking by patients with acute coronary syndrome, who underwent hospital-initiated smoking cessation.

Apicoaortic valved conduit: Potential for progress?

The number of elderly patients who require aortic valve replacement is growing, as is the increase of complicating factors, such as previous coronary bypass grafting and atherosclerotic disease of the ascending aorta. An uncommon surgical option to aortic valve replacement is the apicoaortic valved conduit. In this article the techniques and outcomes of 13 cases of apicoaortic valved conduit insertions in high-risk patients are described. From 2002 through 2005, 13 patients (mean age, 75 +/- 8.7 years; 8 men) with severe calcific aortic stenosis had insertions of an apicoaortic valved conduit because of a porcelain aorta (n = 4), previous coronary bypass grafting (n = 6), or both (n = 3). The off-pump technique was used in 9 patients, and a heparinized miniextracorporeal circulation system was used in 4 patients. Follow-up time was 6 to 33 months. Mean intensive care stay was 2 +/- 2.7 days, and mean hospital stay was 12 +/- 8 days. The 30-day mortality was 15% (2 patients; postoperative days 3 and 28, both caused by myocardial infarction). Mortality later than 30 days postoperatively was 23% (3 patients; postoperative day 45 caused by bilateral pulmonary bleeding because of pneumonia, postoperative day 56 caused by myocardial infarction, and postoperative day 81 caused by pneumonia). The remaining 8 patients were doing well, all in New York Heart Association class I or II at follow-up, with echocardiography showing a low gradient over the valved conduit. The apicoaortic valved conduit in high-risk patients undergoing aortic valve replacement remains a feasible option, with a substantial potential for technical development and progress.

Solitary Massive Right Ventricular Metastasis of Renal Cell Carcinoma Without Inferior Vena Cava or Right Atrium Involvement

Right ventricular metastases from renal cell carcinoma without inferior vena cava or right atrium involvement are rare. A 67-year-old male presented with hematuria and congestive heart failure. Computed tomography revealed a left renal mass. In addition, an intra-cardiac mass was found during the preoperative workup, causing right ventricular outflow tract obstruction. His past medical history included previous coronary bypass grafting. The patient underwent combined radical nephrectomy and removal of right ventricular mass. Pathology confirmed renal cell carcinoma with extensive sarcomatoid features in both the left kidney and right ventricle. His postoperative recovery was unremarkable.

Gender as a primary predictor of outcome after carotid endarterectomy

Objective: Post hoc analysis results of the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study suggest that carotid endarterectomy (CEA) may not be as efficacious in women as it is in men. This study was undertaken for the evaluation of whether there is a difference between men and women in early postoperative outcome after CEA and whether such a difference is consistent across other predictors. Methods: We conducted a retrospective review of all CEAs entered into our departmental registry between January 1, 1989, and November 30, 2000. A total of 3422 CEAs was performed in 3077 consecutive patients. The ratio of men to women was 2:1, and the ratio of patients who were asymptomatic to patients who were symptomatic was 2.3:1. The following in-hospital outcome data were analyzed: transient ischemic attack (TIA), stroke, mortality, combined TIA or stroke, and combined stroke or mortality. Univariate and multivariate analysis results of selected risk factors for an adverse perioperative event were assessed with generalized estimating equation analysis with backwards selection. The following risk factors were considered: gender, preoperative neurologic status, urgency of operation, type of arteriotomy repair, reoperative CEA for recurrent stenosis, history of cardiopulmonary disease, previous coronary artery intervention, simultaneous CEA and coronary bypass grafting surgery, renal failure, and diabetes. Results: Univariate analysis results of gender differences revealed that women were at higher risk for a postoperative TIA or stroke (3.3% for women versus 2.1% for men; odds ratio [OR], 1.6; confidence interval [CI], 1.04 to 2.5; P =.03) and for postoperative stroke or mortality (3.1% for women versus 2.1% for men; OR, 1.6; CI, 1.04 to 2.5; P =.03). Multivariate analysis results showed that female gender was an independent predictor for a postoperative TIA or stroke (OR, 1.7; CI, 1.1 to 2.6; P =.03). Further analysis disclosed that women who were asymptomatic were at greater risk than were men for postoperative stroke or mortality (OR, 2.3; CI, 1.3 to 3.9; P =.003). Conversely, there was no gender association for postoperative stroke or mortality in the consideration of only patients who were symptomatic (OR, 1.0; CI, 0.45 to 2.1; P =.95). The interaction between women and preoperative symptoms approached significance (P =.07) with respect to postoperative stroke and mortality rate, which suggests that the gender effect could be influenced by the clinical presentation. Conclusion: The combined TIA or stroke and stroke or mortality rates are higher in women as compared with men in the postoperative period, but these risks remain acceptable when CEA is performed for appropriate indications. The interaction between symptoms and gender suggests that, in patients who are asymptomatic, women are more likely than are men to have early complications. However, there is no gender difference in patients who are symptomatic. Therefore, despite a low postoperative complication rate, CEA is appropriate in both women who are asymptomatic and women who are symptomatic only if the postoperative TIA, stroke, and mortality rates are appreciably lower than in the natural history of medical management of these patients. (J Vasc Surg 2002;35:748-53.)

Mitral valve replacement through right thoracotomy after coronary arterial bypass grafting with functioning conduits

A 67-year-old man who had undergone coronary artery bypass grafting 3 years previously suffered from severe mitral regurgitation associated with Streptococcal infective endocarditis. He was placed in New York Heart Association functional class III. Preoperative angiography demonstrated good opacification of all 3 conduits implanted in the previous operation. We replaced the mitral valve through an anterolateral right thoracotomy, approaching the mitral valve as an alternative to redoing sternotomy to minimize potential injury to patent grafts. His postoperative course was uneventful. After a 1-month course of antibiotics, the patient was discharged as New York Heart Association class II and at present, 3 months after discharge, is doing well. This approach is an effective alternative to redoing sternotomy for mitral valve operation, especially in patients undergoing a previous coronary arterial bypass grafting via median sternotomy.

Current status of endocarditis prevention

There are currently no randomized and carefully controlled human trials to definitively prove that endocarditis prophylaxis is efficient. Furthermore, most cases of endocarditis are not attributable to a medical procedure. Thus, even with a high level of application of endocarditis prophylaxis only a minority of cases could be prevented. Endocarditis is a rare disease. On the other hand, its morbidity is increasing! In addition, infective endocarditis remains still a major medical concern because of its mortality between 5% and 76%. In addition, in up to 40% of all patients suffering from endocarditis one or more heart valves have to be replaced in the following 5 to 8 years. Without treatment endocarditis has a lethality of 100%. Therefore, there is worldwide agreement that endocarditis prophylaxis is necessary. Combining the recommendations of the German and the American Heart Association, as well as the results of the European consensus conferences, with newer insights into the pathophysiology of endocarditis the following aspects are elucidated: depending on their risk of endocarditis patients are allocated into 3 groups. In the first group there are patients with prosthetic cardiac valves, patients who suffered from previous endocarditis and patients with complex cyanotic congenital heart disease and surgically constructed shunts or conduits of the aorta and/or pulmonary circulation. In these high-risk patients the prophylactic regimen for dental, oral, respiratory tract procedures is oral amoxycillin. In genitourinary and gastrointestinal procedures ampicillin and gentamicin i.v. is recommended. In patients with mostly congenital cardiac malformations, acquired valvular dysfunction, hypertrophic obstructive cardiomyopathy and mitral valve prolapse or thickened leaflets and valvular regurgitation oral amoxycillin is recommended for all medical procedures (second group). The third group consists of patients with isolated secundum atrial defect, previous coronary bypass graft surgery, patients with cardiac pacemakers or defibrillators. In this patient cohort the individual risk of endocarditis is not higher than in the general population. Therefore, endocardits prophylaxis is not recommended.

Tibial bypass for limb salvage using polytetrafluoroethylene and a distal vein patch

Objective: Tibial artery bypass for limb salvage may be required in patients without adequate autogenous vein. The interposition of venous tissue at the distal anastomosis has been advocated to improve the results of prosthetic grafts to tibial arteries. Having reported on technical feasibility and an early experience with polytetrafluoroethylene (PTFE) and a distal vein patch (DVP), we examine the results of this technique with 4-year follow-up. Methods: From July 1993 to July 1999, 514 tibial bypass grafts were performed, with 80 bypass grafts in 79 patients with PTFE/DVP as the conduit. Patient demographics included 39 men and 40 women (mean age, 67 years); 42 had diabetes mellitus (53%), 16 had renal failure (20%), and 48 had Eagle criteria for increased cardiac risk (60%). Indications for revascularization were rest pain in 39 (49%) and tissue loss in 41 (51%). Lack of adequate vein resulted from previous failed lower extremity bypass graft (47 [59%]), previous coronary bypass graft (21 [26%]), unsuitable vein (8 [10%]), and absent vein due to ligation and stripping (4 [5%]). Follow-up ranged from 1 to 48 months. Results are reported as primary patency or limb salvage ± SE. Results: Bypass grafts originated from the common femoral artery (40 [50%]), the superficial femoral artery (6 [8%]), and the external iliac artery (34 [43%]). Recipient arteries included anterior tibial (17 [21%]), posterior tibial (28 [35%]), and peroneal (35 [44%]). Four-year primary patency and limb salvage rates were 62.89% ± 10.6% and 79.21% ± 8.45%, respectively. There was a 24% mortality rate during the follow-up period. Acute failure occurred in 7 grafts with 5 immediate amputations and 2 revisions. A total of 17 grafts failed during the follow-up period, leading to 11 amputations. Conclusion: The DVP technique allows PTFE bypass grafts to tibial arteries with acceptable long-term patency and limb salvage. (J Vasc Surg 2001;33:266-72.)

Dissection of the ascending aorta after previous cardiac surgery: Differences in presentation and management

Objective: This study was undertaken to determine the impact of previous cardiac surgery on the presentation, management, and outcome of late dissection of the ascending aorta. Patients and methods: From 1976 to 1998, type A dissection developed in 56 patients with a history of previous cardiac surgery. Interval from first operation to type A dissection was 49 ± 47 months (0.3-180 months). Previous operations were coronary artery bypass grafting (n = 40), aortic valve replacement (n = 8), and other (n = 8). Results: Type A dissection was acute in 34 patients and chronic in 22. In acute dissection, aortic insufficiency occurred in 50%, malperfusion in 12%, and rupture in 18%; 2 patients (6%) were in hemodynamically unstable condition because of rupture. Of patients with previous coronary bypass grafting, 98% had preoperative coronary angiography. Type A dissection was treated by supracoronary tube graft (84%), Bentall procedure (14%), or local repair (2%). Strategies for managing previous coronary bypass grafting included reimplantation of proximal anastomoses with a button of native aorta (29 patients), interposition graft to pre-existing saphenous vein grafts (9 patients), and new saphenous vein grafts (20 patients). Eight hospital deaths occurred (14%). Conclusions: We conclude that (1) patients having type A dissection late after cardiac surgery infrequently have cardiac tamponade and hemodynamic collapse; (2) patients with previous coronary bypass grafting require coronary angiography, because operative management must account for pre-existing coronary artery disease; and (3) operative mortality is low, and this may be attributable to preoperative hemodynamic stability, delineation of coronary anatomy in those with previous coronary bypass grafting, and operative treatment of coronary artery disease. (J Thorac Cardiovasc Surg 1999;117:252-60)

Clinical predictors easily obtained at presentation predict resource utilization in unstable angina

Objective To determine if a risk prediction model for patients with unstable angina would predict resource utilization. Methods and Results Four hundred sixty-five consecutive patients admitted for unstable angina to a tertiary care university-based medical center were prospectively evaluated from June 1, 1992, to June 30, 1995.The proportion of patients receiving coronary angiography, coronary angioplasty, and coronary artery bypass grafting were analyzed according to four risk groups on the basis of a previously published model: Group 1, <2% risk of major complication; Group 2, 2.1% to 5% risk; Group 3, 5.1% to15% risk; and Group 4, >15.1% risk. Hospital length of stay and estimated cost of hospitalization based on DRG and specific payer ratio of cost-to-charge were also compared between groups. Multiple linear regression analysis was used to determine the influence of estimated risk and procedures on hospital costs. The four groups were well matched for gender, hypertension, tobacco history, and previous percutaneous transluminal coronary angioplasty and myocardial infarction. Group 4 had a higher incidence of previous coronary bypass grafting (35% vs 10%, p = 0.001) and triple vessel or left main coronary artery disease compared with Group 1 (44% vs13%, p =0.041). Group 4 patients were more likely to be admitted to the coronary care unit compared with Group 2 or Group 1 patients (80% vs Group 1: 51% [ p = 0.001]; and vs Group 2: 53% [ p = 0.001]), more likely to receive heparin (87% vs 71%, p = 0.007), and more likely to receive a β-blocker or calcium channel blocker (89% vs 74%, p = 0.008) than Group 1. Coronary angioplasty rates were similar for all groups, but Group 4 patients were more likely to receive coronary bypass grafting than Group 2 or Group 1 (27% vs Group 2:12%, p = 0.004 and vs Group 1: 8%, p = 0.002). Hospital length of stay was highest in Group 4 and lowest for Group 1. Average hospital costs were significantly less in Group 3 than in Group 4, but higher than in Group 1. Multivariate analysis determined a dependency of costs on risk group with Group 2 having costs 31.4% (95% CI= 9.8 to 57.2), Group 3 46.7% (24, 3 to 73.1), and Group 4 75% (46.9 to 110.7) higher than Group1. The use of procedures also significantly increased costs, with PTCA-treated patients having a 44.9% (26.7 to 65.7) increase in costs compared with medically treated patients, and surgically treated patients having a 204.7% increase in costs. Conclusion Resource utilization as assessed by the use of revascularization procedures, length of stay, and hospital costs are influenced by patient acuity estimated from a prediction model on the basis of estimated risk of cardiac complications. The model exerts independent influence on cost even after adjustment for various procedures. The use of revascularization procedures, especially coronary artery surgery, remains a large determinant of hospital cost. (Am Heart J 1998;136:373-81.)