Perioperative Infarction Rate Research Articles

Does Bilateral ITA Grafting Increase Perioperative Complications? Outcome of 6,476 Patients with Bilateral versus 5,020 Patients with Single ITA Bypass.

Despite the superior patency of internal thoracic artery (ITA) grafting compared with saphenous veins, frequency of bilateral ITA (BITA) grafting in Europe is still approximately 10%. The aim of the present study was to compare the early outcome of patients receiving either BITA or single ITA (SITA) grafting. A total of 11,496 patients with isolated coronary artery bypass grafting (CABG), operated between January 1996 and December 2012, were analyzed retrospectively; 0.6476 patients (mean age 65.2 years, 81.3% males) received BITA and 5,020 patients (mean age 66.6 years, 76.7% males) SITA grafting. Mean body mass index (BMI) was 27.2 versus 27.4, p = 0.017. Incidence of diabetes was 28.9 versus 28.4%, p = 0.08. Ejection fraction (EF) > 50 was 71.3% (BITA) versus 66.3% (SITA), p < 0.001. Elective operations were performed in 88.4% (BITA) versus 83.3% (SITA), and urgent/emergent surgery was necessary in 11.6% (BITA) versus 16.7% (SITA), p < 0.001. Number of grafts was 3.76 (BITA) versus 3.06, p < 0.001. Duration of surgery (194.4 vs. 180.4 minutes) as well as X-clamp time (60.4 vs. 51.7 minutes) was prolonged for BITA, p < 0.001. Perioperative infarction rate revealed 3.2% (BITA) versus 3.6%, p = 0.54. Frequency of rethoracotomy due to bleeding was higher in the BITA group (3.8 vs. 2.1%), p < 0.001. Sternal instabilities occurred in 2.3% (BITA) versus 2.2%, p = 0.749. Duration of mechanical ventilation < 12 hours was 74.6 versus 77.1%, p = 0.09 and duration of in-hospital stay was 10.5 versus 10.4 days, p = 0.68. Thirty-day mortality was 2.4% (BITA) versus 3.0%, p = 0.09. Multivariate analysis identified prolonged duration of surgery, BMI > 30, emergent operations, advanced age, and BITA grafting as predictor for sternal instabilities. EF < 30%, advanced age plus emergency were associated with increased 30-day mortality. CABG using BITA can be performed routinely with good clinical results and low mortality. Compared with SITA grafting, bleeding complications were enhanced.

Beating-Heart Coronary Artery Bypass Grafting Using a Miniaturized Extracorporeal Circulation System

Experience with miniaturized coronary artery bypass (CAB) systems in coronary artery bypass graft (CABG) surgery on the beating heart is limited. We used a relatively new miniaturized cardiopulmonary bypass (CPB) system, which we termed assisted CAB (ACAB), to perform CABG on the beating heart in 110 patients, and we analyzed clinical outcomes in this patient group. Between January 2004 and September 2006, we used ACAB to perform CABG on the beating heart in 110 patients. The mean patient age was 73 +/- 8.1 years. The ACAB system uses a small prime volume of only 500 mL, and the circuit is shorter than that used in conventional CPB. In addition, the tubing and oxygenator systems were surface-coated with phosphorylcholine. The initial heparin dose was 150 IU/kg, with a target activated clotting time of >250 seconds. With this management, none of the patients experienced system thrombosis. We did not use cardioplegia or aortic crossclamping and did not routinely retransfuse cardiotomy blood. Observational data for the 110 patients were analyzed. The mean number of anastomoses performed was 2.67. The rate of perioperative infarction was 1.8% (2 patients). Perioperative mortality was 7% (8 patients). The mean EuroSCORE for all patients was 6.4 +/- 4, whereas it was 13.75 +/- 6.18 for the patients who died. Mean CPB time was 64.96 +/- 16.66 minutes. In our experience, beating heart CABG supported by a miniaturized CPB is a safe procedure with acceptable perioperative results.

Invited commentary

Coronary endarterectomy (CE) is an important tool for the cardiac surgeon, because the number of patients with severe coronary artery disease continues to increase. To identify risk factors for adverse outcome after CE, Sirivella and colleagues [1Sirivella S. Gielchinsky I. Parsonnet V. Results of coronary artery endarterectomy and coronary artery bypass grafting for diffuse coronary artery disease.Ann Thorac Surg. 2005; 80: 1738-1745Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar] retrospectively compared a group of CE patients with a group of patients operated on with conventional coronary artery bypass graft surgery. Despite the fact that the patients in the CE group were at higher risk, with increased incidence of comorbidities and three-vessel disease, the operative mortality and the incidence of major postoperative morbidity were comparable between the groups. At long-term follow-up, actuarial survival and freedom from return of angina were also comparable between the two groups. The authors have to be congratulated for this extremely large series of CEs with good results. The study highlights some important aspects regarding the use of CEs. CE of the left anterior descending artery (LAD) had comparable outcome (ie, mortality and perioperative infarction rate) with CEs of the other major vessels. This finding may encourage the use of CEs in severely calcified LADs, and consequently, in my opinion, a wider use of the internal thoracic artery to revascularize this vessel. In the CE group, 60% of the myocardial infarctions were localized in the territory supplied by an endarterectomized vessel. Therefore I agree with the authors that, in patients in whom adequate CE is not feasable, CE should be used with caution. In such patients, alternative treatments such as transmyocardial revascularization or angiogenic growth factor have to be considered. The technique of endarterectomy, that is limited incision and traction versus an “open” technique, did not significantly influence results. This underlines that, in experienced hands, both techniques have a comparable, clinical outcome. Unfortunately, postoperative graft visualization and postoperative myocardial viability studies were not routinely performed in this study. Therefore, the question as to how much benefit CE adds to patients with diffuse coronary artery disease compared with conventional coronary surgery remains unanswered. Endarterectomy with bypass grafting is a well established therapy for all coronary arteries. In patients with a life expectancy of more than 10 years, a more aggressive use of arterial grafting, not only for the LAD, is justified because of the potential improvement of long-term results.

Perioperative myocardial injury: individual and population implications

It is generally understood that patients who have cardiovascular disease are at risk of cardiac complications after surgery. In patients undergoing major or vascular surgery, the risk of such complications can be signi®cant. Eagle and colleagues studied patients enrolled on the CASS (Coronary Artery Surgery Study) registry who subsequently underwent non-cardiac surgery. They reported a perioperative myocardial infarction rate of 8.5% in patients with medically managed coronary artery disease who underwent vascular surgery. The authors de®ned high-risk surgery as surgery associated with a risk of perioperative death or myocardial infarction of greater than 4%. Abdominal surgery, thoracic surgery, and head and neck surgery fell into this category. For patients undergoing these types of surgery who had medically treated coronary artery disease, the overall perioperative myocardial infarction rate was 2.7% and the overall death rate 3.3%. This compared with rates of 0.8 and 1% respectively in patients undergoing similar surgery who did not have coronary artery disease. Data such as these are often considered with information on the prevalence of coronary artery disease to obtain some indication of the population burden of disease. For example, in 1990 Mangano stated that 25 million patients undergo major surgery in the USA each year and suggested that perhaps 6±7 million of these people are at risk of perioperative cardiac complications. Such estimates suggest that perioperative cardiac complications are both a major issue in the care of individual surgical patients and a major public health issue. This review will examine in more detail the population impact of perioperative cardiac morbidity and the implications of this for the individual patient.

OPCAB: Reducing the Perioperative Risk Avoiding Extracorporeal Circulation in CABG Surgery

BACKGROUND: In recent years, minimally invasive techniques have entered many areas of surgery. Cardiac surgery, for example, has relied on two different approaches to reduce operative trauma, one by minimizing the incision, the other by avoiding extracorporeal circulation, considered to be responsible for systemic inflammatory response syndrome as well as for neurocognitive disorders. METHODS: In 1999/2000, our department performed 579 CABG operations, 283 without the use of CPB (13 MIDCAB, 270 OPCAB). The demographic data of the two groups of patients are comparable. The OPCAB-patients received 1 to 5 distal anastomoses, 2.7 on average. 62 % of our patients in the off-pump group received at least one anastomosis for a marginal branch of the circumflex artery. We employed two different commercially available mechanical stabilization devices to stabilize the epicardium of the anastomotic region (CTS, Octopus II). RESULTS: Perioperative mortality in our OPCAB group was 1.4 % versus a mortality rate of 3.7 % in the on-pump group. There was a trend toward a decreased perioperative infarction rate in the OPCAB patients group (2.8 % versus 4.8 %). Postoperative drop of platelets and CKMB-levels were significantly lower in the OPCAB-group. CONCLUSIONS: CABG without CPB is a safe alternative to the conventional technique with cardiopulmonary bypass, which has been the “golden standard” during the last decades. In perfect cooperation with the anaesthesiologist, even more difficult revascularization procedures concerning anastomoses to the marginal branches are feasible. Perioperative trauma can be reduced avoiding cardiopulmonary bypass, thereby benefiting especially elderly, multimorbid high-risk patients.

Perioperative Myocardial Ischemia: Pathophysiology and Does it Really Matter

Perioperative Myocardial Ischemia: Pathophysiology and Does it Really Matter

Myocardial Protection and Oxyhemoglobin Dissociation Curve

The following correspondence refers to a previously published Clinical Concepts and Commentary article by Warltier et al. (Warltier DC, Pagel PS, Kersten JR: Approaches to the prevention of perioperative myocardial ischemia. Anesthesiology 2000; 92:253–9).Sarasota Memorial Hospital, Sarasota, Florida. barrydoc@gte.netTo the Editor:—In an excellent review of myocardial protection during anesthesia, Warltier et al. 1mention the possibility of improving oxygen availability to the myocardium by a right shift of the oxyhemoglobin dissociation curve. 2–4The beneficial effects of β-blocking drugs also are reviewed. However, the correlation of the well-known fact that β-blockers shift the curve to the right is omitted. This rightward shift may promote oxygen delivery to the myocardium during ischemia. The clear reduction in perioperative infarction rates after β-blockade rests on this fundamental effect.

Surgical angioplasty with exclusion of atheromatous plaques in case of diffuse disease of the left anterior descending artery: 2 years' follow-up.

A new surgical technique of coronary artery angioplasty for diffuse and extensive lesions of the left anterior descending artery (LAD) is evaluated in this study. Ninety-four coronary artery reconstructions (CAR) using a new technique of angioplasty of the LAD were performed: mean age of patients was 59+/-8 years, there were 21 patients with unstable angina, and 21 with recent myocardial infarction (MI). Diseased LAD is bypassed with the internal thoracic artery graft (ITA). The anastomosis is made downstream from the significant proximal lesion of the LAD. A long arteriotomy (from 2 to 12 cm) is performed along the LAD up to the healthy arterial wall, followed by coverage with the onlay graft of ITA in such a fashion as to exclude the plaques from the LAD lumen. The wall of the new reconstructed LAD consisted of 75% of ITA and 25% of native LAD. The remaining part of the native LAD forms a posterior gutter giving the origins of septal and diagonal branches. aortic cross-clamping time was 116 min, operative mortality rate was 3.2% (three patients), peri-operative infarction rate 6.6% (six patients). The follow-up was 29 months (SD=10). Of the 91 survivors, two were lost for follow-up and one died of non-cardiac causes. Of the 88 patients clinically evaluated, 81 were free from angina and other cardiac events, two had new myocardial infarction in a non-grafted area, two were in congestive heart failure, and three in angina class II. Sixty patients underwent angiography. There were 57 perfect-patency CAR (95%), two ITA string sign (competitive flow), two ITA occlusions (2.5%) and no re-stenosis. CAR allows revascularisation of diffusely diseased LAD with acceptable operative mortality and morbidity, 2 years' good clinical results and graft patency. In this series, exclusion of plaques prevented plaque complications.

Influence of normothermic systemic perfusion during coronary artery bypass operations: A randomized prospective study

Objectives: Normothermic cardiopulmonary bypass has been proposed as a more physiologic technique than hypothermic bypass for the maintenance of the body during cardiac surgery. The aims of this study were to investigate the effects of systemic perfusion temperature on clinical outcome after coronary revascularization. Methods: Three hundred patients (mean age 60 ± 9 years, 88% male) were prospectively randomized into three groups: hypothermia (28° C, n = 100), moderate hypothermia (32° C, n = 100), and normothermia (37° C, n = 100). All patients received cold antegrade St. Thomas' Hospital crystalloid cardioplegic solution, and patients in the normothermic group were actively rewarmed during cardiopulmonary bypass (nasopharyngeal temperature 37° C). Results: No differences were found between groups with respect to mortality (1%), intraaortic balloon pump use, perioperative infarctionrates, focal neurologic deficits (1%), intubation time, intensive care unit stay, and postoperative hospital stay. Further stepwise regression analysis identified age and intensive care unit stay as important predictors of the variability in postoperative stay (both R 2 = 0.114, p < 0.001), whereas perfusion temperature remained a nonsignificant explanator. Normothermic perfusion necessitated larger doses of phenylephrine to maintain arterial pressure above 50 mm Hg during cardiopulmonary bypass ( p < 0.0001 vs 28° C, p < 0.01 vs 32° C) but less requirement for electrical defibrillation during reperfusion ( p < 0.05 vs 32°C, p < 0.01 vs 28° C). Total chest drainage was not different between groups, but patients undergoing normothermic cardiopulmonary bypass required less transfusion of blood ( p < 0.05 vs 28° C and 32° C) and platelets ( p < 0.04 vs 32< C, p < 0.001 vs 28° C) in the postoperative period. Conclusions: Cardiopulmonary bypass temperature did not influence early clinical outcome after routine coronary artery bypass operations. Normothermic systemic perfusion was associated with an increased requirement for vasoconstrictors and reduced requirements for electrical defibrillation and transfusion of blood products. (J Thorac Cardiovasc Surg 1997;114:475-81)

Morbidity and mortality in 200 consecutive coronary reoperations.

The morbidity and mortality of coronary reoperations is still higher than in primary myocardial revascularization. In the present paper we analyzed the relation between several preoperative and peroperative variables and the perioperative morbidity and mortality of coronary reoperations. The data of 200 consecutive patients undergoing isolated aortocoronary bypass reoperation were studied by univariate and multivariate analysis. The mean age was 59 years (range 44-83 years), 163 (81%) patients were male and 37 (19%) female. The overall hospital mortality was 8.5% (17/200), and in 32/200 patients (16%) a perioperative myocardial infarction was noted. By univariate analysis, a myocardial infarction before the initial operation and a myocardial infarction between the initial operation and the reoperation, peripheral vascular disease, diabetes, anginal status and perioperative myocardial infarction were identified as factors influencing the operative mortality. Multivariate analysis identified perioperative myocardial infarction and anginal status as predictors of hospital mortality. Further analysis identified peripheral vascular disease, diabetes, delivery way (ante/retrograde) of cardioplegic solution, and anginal status as univariate predictors of perioperative myocardial infarction. The only significant multivariate predictor of perioperative myocardial infarction was the anginal status. The anginal status (New York Heart Association > or = IV-A) is the dominant variable in predicting the operative outcome in coronary reoperations, and a decrease of the operative mortality and perioperative infarction rate can be expected by avoiding 'so called' emergency reoperations.

Eighteen-year follow-up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for stable angina.

The 18-year effect of bypass surgery compared with medical therapy on survival, incidence of myocardial infarction, and relief of angina was evaluated in 686 randomized patients with stable angina in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery. The primary treatment comparisons were made according to intent to treat; 44% of the entire medical cohort had bypass surgery during a median follow-up of 16.8 years. Overall 18-year survival rates were 33% for medicine compared with 30% for surgery (p = 0.60). Survival rates for high-risk patients without left main disease, which had shown a significant advantage for surgical therapy up to 11 years, were 23% medicine versus 24% surgery for patients with three-vessel disease and impaired left ventricular function (p = 0.49) and 22% versus 25% for those with multiple clinical risk factors (p = 0.12). For patients with two-vessel disease, who had significantly better survival with medical therapy at 11 years, rates were similar at 18 years in the two treatment groups (34% medicine versus 30% surgery, p = 0.09). Cumulative 18-year myocardial infarction rates (fatal plus nonfatal) were 41% in medical and 49% in surgical patients (13% perioperative infarction rate), p = 0.15. Nonfatal infarction rates were lower with medical than with surgical therapy (32% versus 44%, p = 0.015), but fatal infarction rates were similar (14% medicine versus 13% surgery, p = 0.62). The combined rate of myocardial infarction or death was also lower with medical therapy (75% versus 82%, p = 0.016). In contrast, surgery reduced mortality after myocardial infarction by 35% at 10 years (p less than 0.001) but only by 13% at 18 years (p = 0.09). The percent of medical and surgical patients who were angina-free was 3% versus 22% (p less than 0.001) at 1 year and 4% versus 12% (p less than 0.001) at 5 years compared with rates of 6% versus 5% (p greater than 0.50) at 10 years and 3% versus 4% (p greater than 0.50) at 15 years. The benefits of coronary artery bypass surgery on survival, symptoms, and postinfarction mortality were transient and lasted fewer than 11 years. The benefits began to diminish after 5 years, when graft closure accelerated. Surgery was effective in reducing mortality only for patients with a poor natural history. Low-risk patients, who had a good prognosis with medical therapy, derived no survival benefit with surgical therapy at any time during the follow-up period. Regardless of risk, surgery also did not reduce the incidence of myocardial infarction or the combined incidence of infarction or death.

Coronary Endarterectomy in Patients with Diffuse Coronary Disease

Diffuse multivessel disease can limit a complete revascularization in patients undergoing coronary bypass surgery. It is considered that coro nary endarterectomy (CEA) offers a reasonable chance for this special group of patients. Among 2415 patients undergoing coronary bypass surgery, a CEA of the right and/or left coronary system had to be performed in 397 patients with diffuse multivessel disease. Completeness of the procedure was controlled intraoperatively by dye perfusion and angioscopy. One hun dred one patients gave informed con sent to be reinvestigated clinically and by angiography at an average of forty-three months after surgery. The thirty days mortality after additional CEA was slightly in creased at 3.8%. Also the periopera tive infarction rate increased at 9.3 % . The long-term analysis re vealed a late mortality of 5.5%. Cor onary angiography showed a patency rate of the endarterectomized vessels of 81.2 %; 91% of the patients being reinvestigated showed an improved or asymptomatic clinical status. Despite a slightly increased risk, CEA proved to be a feasible therapy in this strictly limited group of pa tients, in whom conventional bypass surgery offers poor chances and who otherwise would even be candidates for transplantation.

Coronary artery bypass surgery in patients over age 70 years: report from the Milwaukee Cardiovascular Data Registry.

Between 1972 and 1985, 674 coronary bypass patients greater than or equal to 70 years (70% male, mean age 73 years) were among 10,622 patients with both catheterization and operative data entered into the Milwaukee Cardiovascular Data Registry. These greater than or equal to 70 years patients were analyzed regarding the operative morbidity, the 30-day operative mortality and the operative mortality's relation to coronary artery disease and ventricular wall motion abnormalities. The operative mortality was not different for the 174 patients operated upon before and the 500 patients after 1980. A mean of 3.4 grafts were placed during surgery. The complications encountered included a 7.1% perioperative infarction rate, a 4.2% incidence of cerebrovascular accident, a 3.6% incidence of reoperation for bleeding, a 2.4% incidence of renal failure, and a 2.1% incidence of pulmonary embolism. The overall operative mortality was 7.4%. The extent of coronary artery disease was distributed among patients such that 8.4% had single-, 28.0% had double-, and 63.6% had triple-vessel disease. The operative mortality as related to the extent of coronary artery disease was 5.2% for single-, 8.9% for double-, and 7.0% for triple-vessel disease. The operative mortality was 6.7% with no and 7.9% with left ventricular wall motion abnormalities. The operative mortality was 1.9% with 1 segmental wall motion abnormality, and increased to 13.3% (p less than 0.05) with 4-6 segmental wall motion abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty: A growing surgical problem

The incidence of prior percutaneous transluminal coronary angioplasty in surgical cases is nearly doubling yearly. In 1985, 11.4% of our bypass patients had one or more prior angioplasties. One hundred thirty-five patients with prior angioplasty are compared to 2,205 patients without angioplasty undergoing surgical revascularization. The mortality is 3.2 times higher in the angioplasty patients than in the control patients and the perioperative infarction rate is 2.5 times higher. Forty-four patients were taken directly to the operating room from the catheterization laboratory, 50 were operated on within 10 days, and 41 underwent operation more than 10 days after angioplasty. All of these late failures were of the lesion previously dilated. The infarction rate was less in patients taken immediately to the operating room on an emergency basis than in those whose operation was delayed up to 10 days (30% versus 70%). All patients who died had angioplasty of the anterior descending coronary artery. Angioplasty of this artery increases operative mortality should surgical treatment become necessary acutely. Patients should be informed before angioplasty of the increased surgical risks after a failed angioplasty procedure.

Cardiac surgery in a private hospital. With special reference to coronary artery surgery.

In a four-year period in a private hospital there were 1396 open heart operations of which 1275 were for isolated coronary artery disease. The various techniques that were used for coronary artery reconstruction were saphenous vein grafts and internal mammary artery grafts, both singly and sequentially, and endarterectomy. The operative mortality for isolated coronary artery surgery was 1.1% and the perioperative infarction rate was 2.1%. When combined with an endarterectomy of the right coronary artery, the mortality was 3% and the infarction rate was 4% (not significant); when combined with endarterectomy of the left anterior descending coronary artery, the mortality was 11.7% (not significant), and the infarction rate was 11.7% (not significant). The operative risk was no higher in patients with poor ventricular function.

Coronary artery bypass surgery. A community hospital's experience.

The initial phase (1982) of a comprehensive surgical audit at a large community hospital involved 325 consecutive patients undergoing coronary artery bypass surgery. The resulting data were compatible with the findings of the Coronary Artery Surgery Study. Mean patient age was 57.5 +/- 8.8 years. Revascularization was complete in 77% of patients. Perioperative infarction rate was 4.6%, and in-hospital mortality was 1.2%. Operative risk was highest in those with left main coronary artery stenosis greater than 70%. Age, sex, and ventricular function status did not adversely affect survival.

Unstable Angina Pectoris: Comparison with the National Cooperative Study

Seventy-eight patients having prolonged pain (greater than 20 minutes) with transient S-T segment and T-wave changes and coronary artery bypass were compared to 288 patients previously reported in the National Cooperative Study on the treatment of unstable angina pectoris. Clinical characteristics observed in the present study that differed from those of the National Cooperative Study included a more chronic anginal pattern, slightly older age, greater number of women, and higher incidence of prior myocardial infarction. The severity of vessel disease was the same for both groups. Left ventricular function was slightly better in the present series. The incidence of perioperative infarction in the present series (3.8%) was significantly less than that for surgical patients reported in the National Cooperative Study (17%). Hospital mortality was also less: 1.2% versus 2.0 and 3.0% for the medical and surgical patients, respectively, in the National Cooperative Study. Late myocardial infarction was 11% and 13% at 30 months for medical and surgical patients in the National Cooperative Study, and only 3% at 43 months in the present surgical series. Actuarial survival for the entire patient population was 95% at 42 months. The reduced hospital mortality and perioperative infarction rates were attributed to immediate operation once acute myocardial infarction has been ruled out, advances in surgical and anesthetic technique, selection of patients with preserved left ventricular function, and a trend toward complete revascularization.

Early and late results of combined endarterectomy and coronary bypass grafting for diffuse coronary disease

Between October 1969 and December 1979, a total of 440 patients who had diffuse coronary artery disease were treated with combined endarterectomy and coronary bypass grafting. This constitutes 42 percent of all patients operated on at the same institution during this period. Six hundred eight endarterectomies were performed, 329 on the right coronary artery, 227 on the left anterior descending coronary artery and 52 on the left circumflex coronary artery. The early mortality rate was 4.3 percent and the late mortality rate 9 percent during a mean follow-up period of 47 months. The perioperative infarction rate was 15 percent. Ninety-five percent of survivors were asymptomatic or in improved condition. Only 11 patients were lost to follow-up study. Three hundred fourteen patients (71 percent) were reinvestigated with coronary and graft arteriography 1 month to 8 years postoperatively. The early patency rate of grafts to the endarterectomized vessels was 85 percent and the late patency rate (1 year or more) was 77 percent. The runoff was good in 79 percent, fair in 14 percent and poor in 7 percent of grafts. Endarterectomy is a valuable additional procedure in the management of patients with diffuse coronary artery disease.

Myocardial Protection with Cold Blood Potassium Cardioplegia during Prolonged Aortic Cross-Clamping

The efficacy of cold blood potassium cardioplegia during periods of aortic cross-clamping (greater than 100 minutes) was assessed in 127 patients undergoing a variety of open-heart surgical procedures at New York University Medical Center from January, 1978, to April, 1979. Ischemic intervals ranged from 100 to 267 minutes (mean, 128 minutes). Cardiac-related deaths occurred in only 3 patients (2.4%), and overall operative mortality was 8.7% (11 patients). The rate of perioperative infarction was 10%. Fourteen patients (11%) required vasopressor support or balloon counterpulsation after cardiopulmonary bypass despite the lengthy cross-clamp intervals. Multivariate analysis revealed no significant relationship between the length of cross-clamp time and operative mortality ( p = 0.29), incidence of perioperative infarction ( p = 0.54), or the occurrence of low-output syndrome postoperatively ( p = 0.68). These findings suggest that cold blood potassium cardioplegia provides adequate myocardial protection when periods of arrest as long as 3 to 4 hours are required for complex cardiac surgical procedures.

Manual Coronary Endarterectomy with Saphenous Bypass: Experience with 263 Patients

From January, 1972, until August, 1980, 271 manual coronary endarterectomies with bypass were performed in 263 patients. All patients underwent additional cardiac procedures simultaneously. The group contained 254 distal right and 17 left endarterectomies (including 8 double endarterectomies). Clinical follow-up was 100%, operative mortality was 2.3% (6 out of 263), and the rate of perioperative infarction was 4.9% (13 out of 263). Cineangiography was performed on 72 patients between 1 and 60 months after operation (mean, 15.4 months). Patency was 85% (61 out of 72). Endarterectomy in a dominant right coronary artery could be planned electively. Left coronary endarterectomy was performed only when diffuse disease prevented standard bypass. Coronary endarterectomy may be used to extend operability with excellent clinical results, low perioperative mortality, and high late patency. Careful attention to technical aspects of core removal and myocardial protection are necessary for consistent results.