Biomedical subjects
Publications and source records attributed to F Simonet.
We present, with echocardiographic and intraoperative findings, a rare case of left ventricular-to-right atrial communication (Gerbode defect) after endocarditis associated with Staphylococcus aureus. (Tex Heart Inst J 1995;22:100-2)
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In recent years coronary artery bypass grafting (CABG) has been extended to include patients with very low left ventricular ejection fractions (LVEF), also frequently with co-existing mild to moderate mitral valve regurgitation (MR). The question is, should such a MR be corrected simultaneously with a myocardial revascularization or not? Between January 1989 and November 1994, 56 patients with preoperative LVEF < or = 25% and echocardiographic evidence of co-existing MR (Grade I: 41%, II: 46%, III: 13%) underwent primary CABG. None of them had simultaneous mitral valve surgery. Twenty-nine patients (52%) had a pulmonary artery pressure (PAP) > 40 mmHg. The mean preoperative LVEF was 17.9 +/- 4.6 (10-25), mean PAP 44.2 +/- 16.1 mmHg. An average of 4.5 +/- 1.5 grafts/patient were placed and five patients had simultaneous repair of a post-infarction left ventricular aneurysm. The overall mortality was 3.6% (2/56). Transient post-operative low cardiac output syndrome occurred in 16 patients (29%). Twenty-one patients (38%) had no postoperative complications at all. The 54 hospital survivors were followed up over a mean period of 12 months (3-36 months). There was one death (eight months postoperatively) and two graft occlusions, not requiring reoperation. At the end of the follow up echocardiography showed that 50 patients (93%) had no (31 patients) or only a very mild Grade I MR (19 patients). Four patients had Grade II MR, none of them requiring mitral valve surgery. All patients improved their NYHA functional class, from 3.4 +/- 0.8 to 1.9 +/- 0.7 and LVEF from 17.9 +/- 4.6 to 44.2 +/- 7.4 (p < 0.001). Coronary artery bypass grafting is a possible treatment for patients with very low LVEF, provided the patient has a two- or three-vessel disease with significant coronary artery stenosis (> 70%) and angina. Mortality and morbidity are low. Moderate co-existing MR (Grade I-III) seems to normalize after myocardial revascularization and should not be surgically corrected therefore at the primary operation.
BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.
In order to identify peroperative risk factors and to evaluate different etiological factors in developing postoperative gastrointestinal complications, clinical variables were studied in 3493 patients undergoing adult cardiac surgery. There were 86 gastrointestinal complications, 2.9%, with an overall morality among these of 22.1%: the mortality rate was 3.9% for all patients undergoing cardiac surgery at our institution (p < 0.001). Paralytic ileus, intestinal ischemia, and acute cholecystitis were the most frequently seen complications. Arterial hypertension, smoking and poor preoperative cardiac function, clinical instability, and the need for an emergency operation were distinct clinical risk factors. Cardiopulmonary bypass time was, by itself, not an important factor. Embolic etiology was also ruled out. The incidence of peroperative myocardial infarction, low postoperative cardiac output necessitating massive use of vasopressor substances and/or intraaortic balloon pumping were significantly more often observed in patients who subsequently developed gastrointestinal complications. The common etiological factor in developing gastrointestinal complications of any kind, after cardiac surgery, seems to be postoperative splanchnic hypoperfusion with visceral ischemia. In order to reduce postoperative morbidity and mortality it is essential to identify patients at risk, support preoperative poor cardiac function, and to carefully monitor these patients postoperatively for abdominal complications to reach an early diagnosis.
Fourty-seven patients with a least one heart valve operation each who underwent reoperations (Gr. I) were analyzed with special regard to risk factors influencing the perioperative mortality and compared to 203 patients operated for the first time (Gr. II) during the same time period. Mean age was 57.1 years in Gr. I and 64.1 years in Gr. II (p < 0.05). There were no differences between the groups with regard to sex, smoking, obesity, or concomitant peripheral vascular disease. Hypertension, hyperlipidemia, and diabetes were more frequently seen in Gr. I, p < 0.05. A significantly higher number of patients in the redo group (Gr. I) belonged preoperatively to NYHA class III or IV, p < 0.001 and needed emergency surgery more often, p < 0.01, but left-ventricular function did not differ between the groups. There was no significant difference in the position of valves operated or the number of multiple valve replacements/repairs between the groups, and no difference in aortic cross-clamping or cardiopulmonary bypass time. Most patients were referred from other hospitals. Overall perioperative mortality for Gr. I was 6.4% and Gr. II 4.4% (n.s.). Mortality after first reoperation was 5.0%, after second or more 14.3%. Perioperative mortality was related to age, preoperative NYHA class, and urgency of operation in both groups, and to multiple valve replacement/repair in Gr. I. Elective reoperation carried a mortality of 4.8% but emergency reoperation 20%; reoperation mortality was 2.6% for single valves and 25% for multiple valves.(ABSTRACT TRUNCATED AT 250 WORDS)
AIM AND METHODS: Data from patients younger than 75 years (group I, n = 2939) and patients aged 75 years or older (group II, n = 111) who underwent isolated coronary artery bypass grafting (CABG) during a 9-year period (January 1984 to April 1993) were analyzed to determine comparative risk factors for morbidity, early and late survival, and functional outcome. RESULTS: Traditional risk factors (hypertension, hyperlipidemia, diabetes mellitus, and smoking) were significantly more prevalent in group II. The number of patients in New York Heart Association (NYHA) functional classes 3 and 4 before surgery was also significantly higher in group II (P < 0.001), but emergency operations were equally distributed between the groups. Left main-stem stenosis was more frequent in group II patients (P < 0.01), while the number of vessels involved and pre-operative left ventricular function did not differ. Both groups underwent a mean of 4.5 grafts. Internal mammary grafts were placed in 48.4% (1422/2939) in group I and 19.8% (22/111) in group II (P < 0.001). The overall peri-operative mortality rate did not differ between the groups (2.9% for group I and 2.7% for group II). Non-fatal peri-operative myocardial infarction, ventricular arrhythmias, post-extracorporeal circulation disorientation, and temporary renal insufficiency were more prevalent in group II patients (all P < 0.05). Emergency operations and re-operative CABG increased the peri-operative mortality in both groups. The 3-year survival rate was 93% and the 3-year cardiac event-free rate was 88% for the group II patients. Most of the elderly patients (98%) were in NYHA functional classes 1 and 2 at the end of the follow-up. CONCLUSIONS: Even if elderly patients have a slightly higher postoperative morbidity than younger patients, and an increased mortality if operated upon in an emergency, long-term survival and freedom from cardiac events are excellent and justify the continued performance of CABG in patients aged 75 years of age or more.
Replacement of the ascending aorta for aneurysm or dissection remains a complex challenge for cardiac surgeons. Between January 1984 and December 1993, 30 patients have had simultaneous resection of the ascending aorta and aortic valve replacement. Sixteen of them had composite graft replacement of the ascending aorta and the aortic valve with a modified Bentall's technique (Group I). Fourteen patients had supracoronary artery aortic resection and aortic valve replacement (Group II). The mean age was 50.1 +/- 15.3 years (range 23-76). There were 22 men and 8 women. Five patients (16.7%) had aortic dissection, six were operated on an emergency basis. Concomitant coronary artery disease was more frequently seen in Group II (5 patients) than in Group I (1 patient), p < 0.05. Other preoperative patient characteristics did not differ. The overall perioperative mortality was 16.7% (5/30), none of them due to technical complications during surgery. Four patients died in Group I and 1 in Group II (n.s.). Non-fatal myocardial infarction was diagnosed in 1 patient (Group I) and only one neurological complication occurred (Group I), while reexploration for bleeding was performed in 4 cases (13.3%). Four patients in Group I and two in Group II had postoperatively low cardiac output, two of them necessitating intraaortic balloon pump insertion. 43% of the patients had no perioperative complications. At the end of follow-up (n = 25), average 6 months (range 1-52 months), twenty-two survivors (22/25 or 88.0%) were in NYHA functional class 1. Simultaneous ascending aortic aneurysm repair and aortic valve replacement can be accomplished with an acceptable mortality and little morbidity.
A consecutive series of 2645 patients underwent primary coronary bypass grafting while 458 patients underwent reoperative bypass during a 9-year period. The mean age (61 years), sex distribution (83% men) and preoperative risk factors were identical in the two groups. Significantly more patients belonged to New York Heart Association (NYHA) class 4 and were clinically unstable in the reoperative group (P < 0.001). The internal mammary artery was used in 43% of the single operation group but in only 23% of patients who subsequently required reoperation (P < 0.001). In reoperations 61% of the patients had an internal mammary artery graft (P < 0.001). The overall operative mortality rate for single operation was 2.3% (62/2645) versus 9.2% (42/458) for reoperations. Patients with a reoperative interval of more than 1 year had a 8.4% mortality rate, compared with 28% in those reoperated on 1 year or less after the initial operation (P < 0.01). Preoperative myocardial infarction, intra-aortic balloon pump insertion, prolonged ventilatory support and ventricular arrhythmias were all prevalent after reoperations (all P > 0.001), while postoperative myocardial infarctions and re-sternotomy for bleeding did not differ between the groups. Emergency operation, preoperative NYHA class 3-4 and poor left ventricular function were predictors of perioperative mortality in both groups. Left main stem stenosis was an added factor in the reoperative group. After reoperation 93% of the hospital survivors were alive at 5 years after surgery; the cardiac event-free rate was 59% and > 90% of the patients showed improvement of their NYHA class during the follow-up. Reoperative coronary artery bypass grafting is effective, but has an increased operative mortality and morbidity, especially in patients with unstable angina, left main stem stenosis and poor preoperative left ventricular function.
In order to evaluate the potential risks of a patent internal mammary artery bypass at reoperative coronary artery bypass grafting, we have reviewed the records of 233 consecutive patients undergoing reoperative coronary artery bypass grafting between 1 January 1991 and 31 December 1993, including 209 patients having an occluded mammary graft or no mammary graft (Group I) and 24 patients having a patent mammary graft (Group II). With regard to preoperative patient characteristics, the only significant differences between the groups were: Group II patients had a higher preoperative left ventricular ejection fraction than did Group I patients (63.7% +/- 8.9% vs. 52.1% +/- 10.1%, p < 0.001); and Group II patients had received fewer grafts per patient than had patients in Group I (2.2 +/- 1.1 vs 3.6 +/- 1.4 grafts per patient, p < 0.001). There were no entry injuries to the grafts or to the heart in either of the groups. No perioperative mortality was encountered in Group II, while 11 patients died in Group I (p < 0.05). Group II had a significantly higher incidence of reexploration for post-operative bleeding, whereas Group I had a significantly higher incidence of low postoperative cardiac output. The incidence of all other perioperative complications did not differ between the groups. The results of this study support the use of mammary grafts even in patients who are likely to need repeat coronary artery bypass grafting and certainly does not disqualify such patients from a 2nd operation.
Clinical variables were studied in 3129 patients undergoing coronary artery bypass grafting to identify patients at risk of abdominal complications and common etiologic factors in the development of such complications. Seventy-three gastrointestinal complications occurred (2.3%), with an overall mortality rate of 16.4% compared with a mortality rate of 3.4% for all patients undergoing bypass grafting (p < 0.001). Cholecystitis and intestinal ischemia were the most frequently encountered complications. Multivariate analysis demonstrated that preoperative hypertension, New York Heart Association classes III and IV, preoperative left ventricular ejection fraction less than 40%, age greater than 70 years, reoperation, and urgent operation as independently and significantly associated with gastrointestinal complications. In contradiction to previous reports, no significant correlation existed between gastrointestinal complications and cardiopulmonary bypass time, 99.8 +/- 35.8 versus 101.2 +/- 39.8 minutes. Perioperative myocardial infarction and immediate postoperative hypotension with low cardiac output necessitating substantial inotropic pharmacologic support or intraaortic balloon pumping were significantly more prevalent in patients who had gastrointestinal complications (all p < 0.001). Furthermore, multivariate analysis revealed that postoperative low cardiac output was a significant, independent predictor in the development of gastrointestinal complications of any kind after coronary artery bypass grafting. Postoperative splanchnic hypoperfusion could therefore be a common etiologic factor.
We report two cases of aortic dissection during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Aortic dissection occurring during coronary angioplasty may be self-limiting, but it may also be life-threatening and may call for urgent surgical repair.
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The use of the internal mammary artery for revascularization of the coronary arteries has expanded over the last years. In a series of 250 consecutive coronary artery revascularizations, there was at least 1 internal mammary-coronary artery anastomosis in 222 patients (89%) and multiple internal mammary-coronary artery anastomoses were performed in 77 patients (31%). During the revascularization procedure, weaning from cardiopulmonary bypass was not possible in 4 patients with internal mammary-coronary artery anastomoses. These 4 patients showed signs of left ventricular failure, and additional saphenous vein bypass to the left anterior descending coronary artery, already revascularized by the left internal mammary artery, was performed. Weaning from cardiopulmonary bypass was then possible in 3 out of 4 patients. Thus, in some patients (1.2%), internal mammary-coronary artery anastomoses provide inadequate nutritional support for the myocardium.
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