RE: JW Butany, TE David, M Ojha. Histological and morphometric analyses of early and late aortocoronary vein grafts and distal anastomoses.
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Coronary Artery Bypass↗
Biomedical subjects
G M FitzGibbon
Publications and source records attributed to G M FitzGibbon.
Minimally invasive coronary artery bypass: a series with early qualitative angiographic follow-up.
BACKGROUND: Notwithstanding the advantages offered by minimally invasive coronary bypass, valid concerns have been raised about the technical accuracy of the distal anastomoses that can be fashioned on a beating heart. The main objective of our study was to undertake early and complete qualitative angiographic graft analysis in all patients undergoing this procedure. METHODS: All enrolled patients (25) from January to October 1996 who had bypass done by one surgeon via left minithoracotomy (19) or median sternotomy (6) on a beating heart underwent postoperative angiography within 4 to 6 hours. These angiograms were then reviewed for qualitative analysis and compared with a similar series done under conventional cardioplegic arrest. RESULTS: There was 97.5% graft patency (28/29) and no anastomotic occlusions. One internal thoracic artery was damaged. There was no mortality and no perioperative myocardial infarctions. All patients are alive and symptom free. The follow-up is 100% complete and ranges from 15 days to 11 months. Of the 26 anastomoses that could be assessed, 21 (81%) were grade A and 5 (19%) were grade B. In comparison, 24/25 (96%) of the anastomoses fashioned on an arrested heart by the same surgeon were grade A (p = 0.175). CONCLUSIONS: Minimally invasive coronary bypass can be carried out effectively and safely in a select group of patients, and the development of stabilizing devices and proper instrumentation should further improve results.
Anastomosis, Surgical↗
Psychosocial aspects of coronary artery disease related to military patients.
OBJECTIVE: Coronary artery disease (CAD) is a major cause of nontraumatic morbidity and mortality in military personnel. Most studies of the psychosocial impact of CAD have dealt with civilian populations. The purpose of this paper is to highlight differences between military and civilian populations with CAD in 4 areas: depression and anxiety, social support, return to work, and stress. METHOD: A computerized literature search from 1985 to 1995 using the search terms "stress," "cardiovascular," "cardiac," "depression," "military," "anxiety" and "psychosocial" was undertaken. Controlled and prospective studies of civilian patients were selected along with relevant studies involving military populations. RESULTS: Unique characteristics of the military may be important factors in affecting the psychosocial outcome of military patients with CAD. These characteristics include a high level of denial of illness, strong social supports, a powerful military work ethic, and stressful situations unique to the military. CONCLUSIONS: Most studies of the psychosocial impact of CAD are based on civilian populations. A review of available studies suggests that little is known about how military patients adapt to CAD, particularly with regard to symptoms of depression and anxiety, social impairment, and rates of return to work. Studies in this area are needed regarding the psychosocial aspects of CAD in military populations.
Adult↗
Cardiac rupture treatment revisited.
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Canada↗
Adaptation to coronary artery disease: first pilot study in the military.
To determine how a group of 29 male military patients with coronary artery disease (CAD-MIL group) have adapted physically and psychosocially, we compared results from standard questionnaires with those from 39 healthy military men (WELL-MIL group) and 27 male civilian patients with coronary artery disease (CAD-CIV group). There was no difference in the degree of severity of coronary artery disease between the two groups with the disease. The WELL-MIL group reported a higher activity level than the CAD-MIL group, which reported a higher activity level than the CAD-CIV group. Both the CAD-MIL group and WELL-MIL groups had lower levels of state anxiety compared with the CAD-CIV group, and the CAD-MIL group had a better overall psychosocial adjustment score compared with that of the CAD-CIV group. Thus, male military patients with coronary artery disease reported better physical and psychosocial adjustment to their illness than a group of male civilian patients with a similar degree of disease severity. but they were less physically active than healthy military men.
Adaptation, Psychological↗
Coronary-pulmonary steal syndrome.
The development of an internal thoracic artery-pulmonary artery fistula after operation is a rare entity of no clear etiology. We report a patient who underwent coronary bypass reoperation, presented 3 years later with angina on exertion, and upon investigation was found to have an internal thoracic artery-pulmonary artery fistula. This patient was managed conservatively.
Aged↗
Shared care for open heart surgery: 21 years' experience.
OBJECTIVES: To determine whether patients undergoing open heart surgery, the majority coronary artery bypass grafting (CABG), can safely be returned early to the smaller nonspecialized hospital that referred them for postoperative care by a cardiological team. Another objective is to determine what benefits might accrue from this practice and to whose credit. DESIGN: All 1696 patients, 1512 having coronary bypass alone or with ventricular aneurysm repair in 6%, referred from a military hospital with investigative facilities from November 1971 to November 1992 were studied with attention to length of postoperative stay in both hospitals, perioperative mortality and major complications mandating return to the surgical centre (which was almost always for reoperation). Time between initial coronary angiography and CABG was examined to see whether it related to the early return policy. RESULTS: After the first two years, postoperative care at the surgical hospital following CABG was reduced from a mean of 10.4 to 2.4 days, with an 18% reduction in the combined time spent at both hospitals, an estimated reduction of some 48 patient-years at the surgical hospital. A perceived need for active in-patient-rehabilitation and formal postoperative assessment explains the somewhat higher than average 23-day combined hospital stay after CABG. There have been no cardiovascular problems associated with the process of patient transfer and the three postoperative deaths that occurred in the referring hospital do not appear related to early transfer. Most of the 29 patients (2%) returned to the surgical hospital during the postoperative phase to have reoperations; there were three deaths, inevitable in one, scarcely preventable in two and unrelated to the early transfer in all three. Overall perioperative mortality was 2.7%; it was 1.3% for isolated primary CABG, 7.7% for reoperation. Delay between angiography and CABG was less than one day in 9%, less than four weeks in 69% and less than 12 weeks in 96%. It is believed that rapid access to surgical treatment was facilitated by cardiologists' willingness to undertake postoperative care and by the amicable trusting relationship between staff of the two hospitals. CONCLUSIONS: It is possible to transfer patients safely after open heart surgery to a smaller, nonspecialized hospital for postoperative care; there are no significant ill effects from the practice and obvious benefits accrue to several involved parties. This model of shared care may have lessons for those designing or modifying cardiac surgical care programs.
Adolescent↗
Traumatic tricuspid insufficiency: a case followed for 32 years, with a note on early sources.
A healthy young man suffered nonpenetrating chest trauma in an automobile accident in August 1962, sustaining tricuspid valve disruption and insufficiency, a rare event. Clinical diagnosis was confirmed by cardiac catherization, but valve replacement did not take place for 10 years. Since initial valve replacement he has had two further operations to deal with valve malfunction resulting in recurrent tricuspid stenosis. He had been followed, in various hospitals, for more than 32 years. Traumatic tricuspid insufficiency has become more common with the rise of car accidents and steering wheel trauma. It is characterized by the subtlety of presentation in its mainly young male victims, although it may be suspected from simple bedside examination, and by the frequently long delay between injury and overt clinical problem. The unusual history of the earliest clinical descriptions is reviewed.
Adult↗
Interventions for coronary stenosis--a Canadian experience of 30 revolutionary years.
OBJECTIVE: To report 2324 coronary stenosis interventions (Vineberg procedures [VbP], coronary artery bypass graft operations [CABG] and percutaneous transluminal coronary angioplasties [PTCA]), in 1711 patients of a Canadian military hospital between 1965 and 1995 and to report their evolution and interaction in a historical context. DESIGN: Retrospective examination of clinical and angiographic findings in hard records, collected from the beginning for long term follow-up and later embedded in a custom-designed computer database. PATIENTS: Most were male, mean ages 43.2 and 43.3 years for first and second VbPs; 48.9 and 58.2 years for first and repeat CABGs; and 53.4 and 59.9 years for first and repeat PTCAs, respectively; 12% of all patients were 39 years old or younger at the first intervention. INTERVENTIONS: There were 160 VbPs, 1637 CABGs and 527 PTCAs. Of 1711 subjects, 74% had only one procedure, 15% had more than one of the same kind, and 11% had more than one of different kinds. MAIN RESULTS: Perioperative mortality for VbPs was 4.4%; for 'isolated' first CABGs it was 1.4% and 6.6% for reoperations, when other concurrent major cardiac procedures, excepting ventricular aneurysm repair, were excluded. It was 0.4% for PTCAs. Perioperative mortality for all 1761 'isolated' coronary interventions necessitating thoracotomy, during 30 years, was 2.4%. Angiographic follow-up rates were high and some findings are reported, including early postoperative patency rates for 5065 coronary bypass grafts, and long term follow-up data on graft patency and disease. CONCLUSIONS: Each intervention was used to circumvent or relieve coronary stenosis, in the early years when it became available and, later, as was most appropriate for dealing with specific clinical problems. The impact of advances in the evolution of these interventions on therapeutic decision-making is discussed. Finally, tributes are paid to those responsible for making these procedures possible, including a Canadian surgeon whose role was pivotal.
Adult↗
Coronary subclavian steal: a recurrent case with notes on detecting the threat potential.
A 43-year-old military patient with silent myocardial ischemia due to proximal anterior descending coronary artery and major diagonal branch stenoses had left and right internal mammary artery grafts in 1973, with excellent angiographic results. In 1984, silent ischemia recurred, due to proximal subclavian occlusion with collateral subclavian steal from the left internal mammary artery. A carotid-subclavian artery graft required replacement in 1987 and in 1989 for steal recurrence from graft stenosis due to thrombosis/atherosclerosis. The final 12-mm graft remained smooth with conventional anticoagulant therapy. However, in 1994, ostial compromise of the left internal mammary artery reduced flow enough to require relief of the original and unchanged anterior descending stenosis by transluminal angioplasty and stent placement. Observations are made on subclavian steal and simple methods for detecting its potential for occurrence.
Adult↗
Aorta-coronary bypass in patients with coronary artery disease who do not have angina: a brief follow-up fifteen years after the last case reported.
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Angina Pectoris↗
Aortocoronary vein graft spasm during angiography.
OBJECTIVE: To determine the frequency and clinical significance of aorto-coronary vein graft spasm during angiography. DESIGN: Retrospective review of angiograms and subsequent correlation with clinical outcome. PATIENTS: A total of 1264 patients having bypass surgery between 1971 and 1986. MAIN RESULTS: Twenty-four men, aged 31 to 54 years, demonstrated spasm in 31 vein grafts at angiography. Vein graft spasm occurred in 13 anterior descending, 12 right coronary, four marginocircumflex and two diagonal grafts. Spasm occurred less than six months after surgery in six cases, six to 12 months after surgery in 18 cases and five or more years after surgery in two cases. There was technical difficulty associated with the intubation of 15 of the 31 grafts. In all but two of the cases, the graft spasm was proximal. There was ischemic discomfort and/or electrocardiographic changes in nine patients, with ventricular fibrillation in three cases. Three cases of very severe vein graft spasm could be reversed with vasodilators, but in three others it could not be relieved and the grafts occluded irreversibly, leading to myocardial infarction in two patients. CONCLUSION: Aortocoronary vein graft spasm may occur during angiography and may be associated with more technically difficult graft intubation. Severe vein graft spasm may respond to vasodilators but can progress to graft occlusion with myocardial infarction. Aortocoronary vein graft spasm during angiography is not related to any higher incidence of spontaneous graft closure or recurrent angina.
Adult↗
Coronary bypass graft fate: long-term angiographic study.
In 222 patients, 741 venous coronary bypass grafts were studied angiographically early, at 1 year and at a late examination at greater than 6.5 years (mean 9.6) after operation; 565 of these grafts were also examined 5 years postoperatively. Grafts were graded for patency and disease considered to be atherosclerotic and for both extent and profile of lesions. Graft occlusion rates increased steadily from 8% early to 20% at 5, 41% at 10 and 45% at greater than 11.5 years after operation. All grafts were considered free of atherosclerosis early, but disease appeared in 8% at 1 year, increasing to 38% at 5 and 75% at 10 years postoperatively. Increasing involvement of vessel wall area was associated with greater protrusion of lesions into the graft lumen. Diseased grafts became more so at subsequent examinations, with occlusion occurring in many. However, absence of disease had little prognostic significance because diseased and abruptly occluded grafts were generated in those with healthy appearance at earlier examinations. For instance, 82% of very diseased grafts at the 5 year study originated from normal grafts at 1 year and 73% of occluded grafts at 1 year had appeared normal early postoperatively. Of 590 patent grafts free of disease at 1 year, 30% were occluded at the late examination, 76% of those patent were diseased, 55% of these were diffusely diseased and 35% were greater than 50% narrowed. Only 17% of the original 590 patent grafts were healthy at this time. Bypass graft atherosclerosis severely limits the long-term utility of these grafts. It is suggested that the solution may lie in some powerful drug regimen.
Adult↗
Atherosclerosis of coronary artery bypass grafts and smoking.
Follow-up angiography was performed at selected intervals on 340 men who had undergone coronary artery bypass surgery. There were 1160 grafts, but 112 were excluded from study because they occluded shortly after the operation. After 5 years 115 patients were smokers and 225 were nonsmokers. The mean number of grafts per patient was similar in the two groups. We classified each graft according to irregularities in graft outlines and graft patency and found disease-free grafts in 39% of the smokers and 52% of the nonsmokers; the proportion of diseased or occluded grafts was greater in the smokers than in the nonsmokers. Our results do not identify the effect of smoking cessation after bypass surgery, but they do suggest that men who continue to smoke are at significantly greater risk of atherosclerosis and occlusion than nonsmoking men.
Angiography↗
Atheroembolic perioperative infarction during repeat coronary bypass surgery: angiographic documentation in a survivor.
We report the case of a patient in whom a myocardial infarction complicated a coronary bypass reoperation. We believe the infarction was associated with embolic occlusion of a large coronary branch by atheroma, which we demonstrated in a previous bypass graft preoperatively and did not see in the postoperative study. We are not aware that atheroembolism of a large coronary branch has been reported before in a survivor of reoperation.
Adult↗
Coronary artery disease and coronary bypass grafting in young men: experience with 138 subjects 39 years of age and younger.
One hundred thirty-eight men aged less than or equal to 39 years had coronary bypass grafting during a 13 year period. Angina was the presenting symptom in 77% and of these patients, one-third had unstable angina. More than half of the patients had experienced at least one myocardial infarct. There was a high incidence of coronary risk factors, especially smoking. Nineteen patients (13.8%) had left main coronary artery stenosis (it was isolated in two); 13.8, 24.6 and 60.2% had single, double and triple vessel disease, respectively. Left ventriculograms showed serious functional impairment in 42%. A total of 461 coronary bypass grafts, 3.34 per patient, were placed; almost all were vein grafts. There were no operative deaths. Transmural myocardial infarction occurred in 4.3% of patients. All bypass grafts were opacified angiographically early after operation, 95% at 1 year, 56% at 5 years and 26% at 10 years after operation. Some patients also had coronary angiograms, dictated by clinical events, between 1 and 5 and between 5 and 10 years postoperatively. Patency rates for bypass grafts were comparable with those previously reported and were acceptable, although they decreased with time. However, increasing evidence of atherosclerosis of bypass grafts was seen beyond 1 year, particularly beyond 5 years. Of 23 subjects with a coronary bypass reoperation, 2 died and 44% had perioperative transmural myocardial infarction. During follow-up, 13.8% of the patients died, survival being 95, 84 and 76% at 5, 10 and 12 years, respectively. It is considered that the patients were advantageously treated with coronary bypass grafting especially in the short-term. However, bypass graft patency steadily decreased with the passage of time and graft atherosclerosis became an increasingly important problem.
Adult↗
Sequential coronary bypass grafts. Long-term follow-up.
Sequential venous coronary bypass grafts have presented problems, mainly because of commonly reported differences between patency of side-to-side and end-to-side vein-coronary anastomoses. Better to define this, we have studied sequential anastomosis grafts done during a 13 year period. We concentrated specifically on 212 "double" grafts with 100% selective angiographic follow-up early, 90% at 1-year, and 44% at 5 years after operation. Four hundred twenty-four control single grafts were studied similarly. We found that patency rates of side-to-side anastomoses were much better than those of end-to-side anastomoses, whether of sequential or control single grafts. Considering specifically diagonal coronary artery-anterior descending coronary artery sequential grafts, the combined patency of all sequential anastomoses theoretically exceeds that of a comparable number of single grafts at all times of study, but the differences are small. Furthermore, there is definite danger of preserving proximal and perhaps limited bypass runoff at the cost of losing distal and perhaps more important myocardial perfusion. On balance, we believe that single vein grafts are to be preferred over sequential grafts unless shortage of conduit material or local aortic wall conditions dictate otherwise.
Coronary Angiography↗
Coronary bypass graft fate. Angiographic study of 1,179 vein grafts early, one year, and five years after operation.
A total of 1,179 vein grafts were studied angiographically in 353 (45%) unselected survivors (male, mean age 45.5 years) of 786 coronary bypass operations. Studies were conducted early (0.96 months), 1 year (12.8 months), and 5 years (59.7 months) postoperatively. A previously described technique was used to grade the patency of the grafts, and a new technique was used to assess intimal irregularity, presumably caused by atherosclerosis; this new technique indicated both intimal surface distribution of disease and profile (relief or elevation). Ten percent, 17%, and 26% of grafts were occluded early, at 1 year, and at 5 years, respectively. Distal anastomotic defects were the commonest cause for low grades in the patency classification. Irregularities in patent grafts increased from 9% at 1 year to 42% at 5 years, with 11% of all the 1 year lesions and 20% of all the 5 year lesions having a high profile (more than 50% graft stenosis); of the lesions categorized as showing the widest surface spread, 17% were in high relief at 1 year and 34% at 5 years. Thus, the lesions we believed to be atherosclerotic proliferated in both surface spread and elevation. All severely diseased grafts at the 1 year study had been normal in outline early; 79% at the 5 year study had been disease free at 1 year. All newly occluded grafts at the 1 year study had been normal in outline and 82% had had good patency early; 78% of newly occluded grafts at the 5 year study had been disease free at 1 year and 77% had had good patency. Normal appearance of the intima in grafts studied at 1 year had no prognostic value for 5 year findings. However, 62% of all grafts with the appearance of intimal disease at 1 year showed deterioration by 5 years, and 28% were occluded. The differences between these outcomes are highly significant (p less than 0.0005). In conclusion, the appearance of intimal irregularity compatible with atherosclerosis in a coronary bypass graft 1 year after operation carried a poor prognosis for adverse angiographic change at 5 years. On the other hand, normally appearing intima at 1 year had no predictive valve for the 5 year study despite a generally better prognosis for nondiseased grafts.
Adult↗