Influence of haemoglobin concentration after extracorporeal circulation on mortality and morbidity in patients undergoing cardiac surgery.
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Adult↗
Biomedical subjects
M Carrier
Publications and source records attributed to M Carrier.
Metabolic monitoring during continuous warm- and cold-blood cardioplegia by means of myocardial tissue pH and PO2.
OBJECTIVES: To study the changes in myocardial tissue pH and PO2 during cold- and warm-blood cardioplegic arrests. DESIGN: An experimental study in dogs. METHODS: Nine dogs underwent the following procedures: 30 minutes with an empty heart beating under cardiopulmonary bypass (control period); 30 minutes of warm (33 degrees C) cardioplegic arrest with a 1:4 mix of crystalloid in blood solution administered continuously at 150 mL/min; 30 minutes of cold (15 degrees C) cardioplegic arrest; and 30 minutes of myocardial reperfusion. The cardioplegic blood solution was administered antegradely through the ascending aorta. MAIN OUTCOME MEASURES: Tissue pH and PO2. Arterial and coronary sinus oxygen content and myocardial consumption calculated. RESULTS: There was a modest but significant increase in the left anterior descending (LAD) and circumflex (Cx) tissue pH throughout the experiment. PmO2 in the LAD territory averaged 44 (7) mm Hg (mean and standard error of the mean) during the bypass period, 123 (23) mm Hg at the termination of warm cardioplegic arrest, 146 (28) mm Hg at the end of cold arrest and 66 (17) mm Hg after reperfusion. Oxygen consumption averaged 0.65 (0.15) mL/min during the bypass period, 0.3 (0.18) mL/min at the end of warm arrest, 0.25 (0.16) mL/min at the end of cold arrest and 0.45 (0.08) mL/min after reperfusion (p < 0.05). Oxygen delivery to the LAD territory was greater than myocardial oxygen consumption by an average of 2.02 (0.4) mL/min during bypass, 2.02 (0.62) mL/min after warm arrest, 2.12 (0.5) mL/min after cold arrest and 1.55 (0.25) mL/min after reperfusion (p > 0.05). CONCLUSIONS: During cardioplegic arrest, tissue PO2 increased and oxygen consumption decreased significantly, whereas tissue pH remained normal, suggesting that continuous warm- and cold-blood cardioplegia maintained aerobic glycolysis during myocardial arrest. Thus, the increase in myocardial tissue PmO2 during cardioplegic arrest reflects the decrease in myocardial oxygen consumption while maintaining oxygen supply.
Animals↗
Predictors of early mortality after heart transplantation: the Canadian transplant experience from 1981 to 1992. The CASCADE Investigators. Canadian Study of Cardiac Transplant Atherosclerosis Determinants.
OBJECTIVE: To determine risk factors for early death following transplantation in the Canadian heart transplant experience. METHODS: A retrospective multicentre study of the Canadian experience in heart transplantation was performed to evaluate the role of risk factors of early death within 30 days following transplantation. Eight hundred and thirty-three patients older than 15 years underwent cardiac transplantation between 1981 and 1992 in 10 centres across Canada. The association between risk factors and early mortality was analyzed with a multivariate logistic model to examine simultaneously the effect of all risk factors. RESULTS: Seventy-eight patients (9%) died during the first month following transplantation. Recipient age (P = 0.549), sex (P = 0.554) and body mass (P = 0.313) had no effect. Baseline pulmonary vascular resistance (P < 0.001) and systolic pulmonary pressure (P = 0.021) before transplantation were related to early death. Older donors (P = 0.027) were associated with a higher rate of early death but there was no relation with donor sex (P = 0.597), body mass (P = 0.413), blood group (P = 0.227) and ischemic time (P = 0.309). Patients with pulmonary vascular resistance of 6 or greater (Wood units) and donors older than 50 years had relative risks of early death five and two times, respectively, those of patients without these risk factors. CONCLUSION: Patient survival averaged 91% one month following transplantation in the Canadian experience between 1981 and 1992. The two predictors most strongly correlated with early death were elevated pulmonary vascular resistance at baseline and older donors.
Adolescent↗
Ischemic threshold during cold blood cardioplegic arrest: monitoring with tissue pH and pO2.
BACKGROUND: Several studies have suggested that measuring interstitial pH and pO2, may be useful to monitor ischemia throughout cardioplegic arrest during cardiac surgery. METHODS: To evaluate the levels of myocardial tissue pH and pO2 that correlate with significant ischemia, 7 dogs underwent cold blood cardioplegic arrest and subsequent incremental episodes of 5, 10, 20 and 40 min of ischemia interrupted by cardioplegic infusion over 10-min periods. RESULTS: Myocardial tissue pH and pO2 were monitored with probes implanted in the anterior and lateral walls of the left ventricle. The release of CK, troponine T and lactate was measured before and after each episode of ischemic arrest. Tissue pH decreased from 7.08+/-0.15 to 7.03+/-0.15 (p>0.05), 7.21+/-0.15 to 7.07+/-0.11 (p>0.05), 7.17+/-0.15 to 6.82+/-0.14 (p<0.05) and 7.0+/-0.18 to 6.63+/-0.08 (p<0.05) after 5, 10, 20 and 40 min of ischemic arrest. Tissue pO2 decreased from 74+/-10 to 38+/-11 mmHg (p<0.05), 83+/-16 to 18+/-4 mmHg (p<0.05), 9+/-22 to 14+/-5 mmHg (p<0.05) and 64+/-24 to 16+/-10 mmHg (p<0.05) after 5, 10, 20 and 40 min of ischemic arrest. CK, troponine T and lactate serum levels increased significantly only following 40 min of ischemic arrest. Myocardial temperature decreased to an average minimum of 14+/-1 degrees C during cardioplegic infusion. CONCLUSIONS: A myocardial tissue pH lower than 7.04 (90% CI, upper limit of 6.82+/-0.14) and a tissue pO2 lower than 22 mmHg (90% CI, upper limit of 14+/-5 mmHg) correlate with anaerobic metabolism and myocardial ischemia during cold cardioplegic arrest.
Anaerobic Threshold↗
[Palliative care, a humanitarian way (Part 1)].
Fully experiencing the last moments of life, in a setting of relative calm and affection, is one of the victories won by the Western movement to rediscover death, which began three decades ago. The author describes the fertile ground from which this movement emerged and makes no pretence of defending medical technology that today supports a multitude of tests in a sort of diagnostic obsessiveness before shifting to a therapeutic obsession in treating people with incurable disease. The author instead advocates the benefits of death with dignity. A well structured analysis of the palliative approach confirms the inalienable nature of human freedom and dignity.
Attitude to Death↗
Propofol or midazolam for sedation and early extubation following cardiac surgery.
PURPOSE: The purpose of this randomized, double-blind study was to evaluate the efficacy of midazolam and propofol for postoperative sedation and early extubation following cardiac surgery. METHODS: ASA physical status II-III patients scheduled to undergo elective first-time cardiac surgery with an ejection fraction > 45% were eligible. All patients received a standardized sufentanil/isoflurane anaesthesia. During cardiopulmonary bypass 100 micrograms.kg-1.min-1 propofol was substituted for isoflurane. Upon arrival in the Intensive Care Unit (ICU), patients were randomized to either 10 micrograms.kg-1.min-1 propofol (n = 21) or 0.25 microgram.kg-1.min-1 midazolam (n = 20). Infusion rates were adjusted to maintain sedation within a predetermined range (Ramsay 2-4). The infusion was terminated after four hours. Patients were weaned from mechanical ventilation and their tracheas extubated when Haemodynamic stability, haemostasis, normothermia and mental orientation were confirmed. Haemodynamic measurements, arterial blood gas tensions and pulmonary function tests were recorded at specified times. RESULTS: There were no differences between the two groups for the time spent at each level of sedation, number of infusion rate adjustments, amount of analgesic and vasoactive drugs, times to awakening and extubation. The costs of propofol were higher than those of midazolam. There were no differences in haemodynamic values, arterial blood gas tensions and pulmonary function. CONCLUSION: We conclude that midazolam and propofol are safe and effective sedative agents permitting early extubation in this selected cardiac patient population but propofol costs were higher.
Adolescent↗
L-arginine prevents cyclosporin A-induced pulmonary vascular dysfunction.
BACKGROUND: Cyclosporin A is known to alter endothelium-dependent responses to different agonists. Few data are available concerning the effect of cyclosporin A on the pulmonary vascular bed. METHODS: The endothelium-dependent responses to acetylcholine (20 micrograms), bradykinin (5 micrograms), and substance P (5 micrograms) were investigated in a dog model of left lung autoperfusion at constant flow. RESULTS: The vasodilator response to bradykinin and substance P was significantly decreased with cyclosporin A (20 mg) administration. The average decreases in pulmonary arterial pressure with bradykinin were 5.4 +/- 1.5 mm Hg and 2.4 +/- 0.4 mm Hg before and after cyclosporin A administration, respectively (p = 0.04). The average decreases in pulmonary arterial pressure with substance P were 4.4 +/- 1.0 mm Hg and 1.8 +/- 0.5 mm Hg before and after cyclosporin A administration, respectively (p = 0.04). The responses to acetylcholine and the endothelium-independent relaxing agent nitroglycerin were not significantly affected by cyclosporin A. The effects of cyclosporin A on endothelium-dependent responses to bradykinin and substance P were overcome by the administration of L-arginine (200 mg/kg intravenously). The decreased response to bradykinin and substance P after cyclosporin A administration was not significantly affected by indomethacin, a cyclooxygenase inhibitor. The pulmonary angiotensin-converting enzyme activity was also measured using [3H]benzoyl-phenylalanyl-glycyl-proline, an inactive angiotensin-converting enzyme substrate. There was an average [3H]benzoyl-phenylalanyl-glycyl-proline hydrolysis of 54% +/- 2% and 55% +/- 2% before and after cyclosporin A administration, respectively (not significant). CONCLUSIONS: The present study suggests that cyclosporin A selectively decreases endothelium-dependent responses to bradykinin and substance P without affecting the cyclic guanosine monophosphate-dependent pathway in the canine pulmonary vascular bed. The decreased endothelium-dependent responses to bradykinin and substance P are not related to increased angiotensin-converting enzyme activity. The toxic effect of cyclosporin A on endothelium-dependent responses is reversible by the administration of L-arginine, a source of substrate for nitric oxide.
Acetylcholine↗
Does retrograde administration of blood cardioplegia improve myocardial protection during first operation for coronary artery bypass grafting?
BACKGROUND: The objective of this study was to evaluate the value of retrograde blood cardioplegia in coronary artery bypass grafting. METHODS: In 1994 and 1995, 224 patients undergoing first-time isolated coronary artery bypass grafting were randomized to antegrade (112 patients, group 1) or retrograde (112 patients, group 2) administration of blood cardioplegia. In group 1, 76 patients were given warm cardioplegia (at 33 degrees C) and 36 had cold cardioplegia (< 20 degrees C), whereas in group 2 cardioplegia was warm in 77 patients and cold in 35. The two randomization groups had similar demographic and angiographic characteristics. The number of grafted coronary arteries averaged 2.9 +/- 0.7 in group 1 and 2.8 +/- 0.7 in group 2. Total duration of cardiopulmonary bypass (78 +/- 23 and 75 +/- 21 minutes) and of aortic cross-clamping (47 +/- 16 and 46 +/- 16 minutes), total volume of infusion of the crystalloid component of cardioplegia (988 +/- 297 and 1016 +/- 595 mL), and total duration of infusion of cardioplegia (23 +/- 10 and 22 +/- 11 minutes) were similar (p > 0.05). RESULTS: There was no death in group 1 and one in group 2 as a result of a pulmonary embolus, for a global early mortality of 0.45%. The numbers of perioperative myocardial infarction (5 versus 3), congestive heart failure (4 versus 5), postoperative hemorrhage (4 versus 4), and stroke (1 versus 2) were also similar (p > 0.05). Release curves of total creatine kinase, creatine kinase-MB by serum activity and mass concentration, and troponin T were not significantly different (p > 0.05) between the two groups. For the 216 patients without perioperative myocardial infarction, peak enzyme release of creatine kinase-MB at 24 hours averaged 23 +/- 22 and 20 +/- 18 IU/L, and that of troponin T averaged 1.1 +/- 1.1 and 1.3 +/- 1.5 micrograms/L at 6 hours for the antegrade and the retrograde groups, respectively (p > 0.05). CONCLUSIONS: Our results indicate no evidence that the retrograde method of cardioplegic infusion improves myocardial protection during first operation for isolated coronary revascularization compared with the usual antegrade route.
Adult↗
Substantial inhibition of neo-intimal response to balloon injury in the rat carotid artery using a combination of antibodies to platelet-derived growth factor-BB and basic fibroblast growth factor.
Thirty percent of patients undergoing percutaneous transluminal coronary angioplasty develop recurrent disease within a year. This is usually due to the rapid accumulation of intimal smooth muscle cells and extracellular matrix, which causes luminal narrowing, and is probably orchestrated by several mitogenic and chemotactic factors, of which platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) appear to be particularly important. We have investigated the effects of administering a combination of neutralizing antibodies directed against PDGF-BB and bFGF on neo-intima development following balloon catheter injury in the rat carotid artery. Purified sheep anti-PDGF-BB and anti-bFGF immunoglobulins (IgGs) were administered singly and in combination prior to mechanical injury and daily until sacrifice, 8 days later. Plasma titres of exogenous anti-PDGF-BB and anti-bFGF were maintained at levels 10-20-fold higher than those required to neutralise the mitogenic and chemotactic effects of 20 ng/ml of PDGF-BB, or 10 ng/ml bFGF in vitro. Used singly, anti-PDGF IgG treatment was associated with a 47% reduction in intimal thickness and a 59% reduction in intimal:medial area ratio; anti-bFGF IgG administration caused a 53% reduction in intimal thickness, and a 50% reduction in intimal:medial area ratio. Treatment with a combination of these antibodies resulted in a 83.8% reduction in intimal thickness (P < 0.05), and a 91% reduction in intimal:medial area ratio (P < 0.01). The latter treatment was also associated with a significantly higher intimal cell density (14.2 +/- 1.6 x 10(3) nuclei/mm2) compared to animals receiving non-immune IgG (7.8 +/- 0.8 x 10(3) nuclei/mm2; P < 0.025), although intimal and medial cell proliferation indices were not significantly different between the groups (P > 0.05). Our results suggest that in this particular model, PDGF-BB and bFGF are the major factors controlling neointimal hyperplasia, and that these growth factors are operating principally via an effect on smooth muscle cell migration and extracellular matrix protein accumulation.
Animals↗
Endogenously elicited antibodies to platelet derived growth factor-BB and platelet cytosolic protein inhibit aortic lesion development in the cholesterol-fed rabbit.
Several studies have indicated that growth factors, such as platelet derived growth factor (PDGF), may be important in atherogenesis. These factors are released from platelets, or expressed by cells of the arterial wall. In order to study their role in atherogenesis more directly, rabbits were immunized with PDGF-BB, platelet cytosolic protein, or human serum albumin (HSA), until high titres of antibody were attained. Atherosclerotic lesions were subsequently induced by feeding the animals with a 2% cholesterol enriched diet. At the end of approximately 3 months, the extent of aortic lesion development was assessed by image analysis of en face preparations of aortae stained with Oil Red-O, and histological segments of aortae taken at the level of the first intercostal artery branch point. The endogenous antibodies were characterized with respect to their cross-reactivity, and ability to neutralize PDGF and platelet cytosol-induced cell proliferation and migration in vitro. The endogenous, anti-PDGF-BB antibody was isoform specific, and neutralized the mitogenic and chemotactic properties of PDGF-BB and rabbit platelet cytosolic protein in vitro. The anti-platelet cytosol antibody partially inhibited the chemotactic and mitogenic properties of rabbit platelet cytosolic protein. Compared to non-immune rabbits (n = 5), animals immunized with HSA (n = 4) had a significantly larger area of aortic lesion involvement (P < 0.01), whereas aortic lesions in rabbits immunized with PDGF-BB (n = 5), or platelet cytosolic protein (n = 7) were significantly smaller than either non-immune animals, or animals immunized with HSA (P < 0.05). The same pattern was observed for other measures of aortic lesion involvement including aortic intima:media ratio at the level of the first intercostal artery. These data suggest that PDGF-BB, and possibly other platelet-associated growth factors, are involved in cholesterol-induced atherosclerosis.
Animals↗
Epidemiological study of Candida spp. colonization in cardiovascular surgical patients.
Candida infections involve multiple risk factors. Among the independent risk factors identified, the degree of colonization of Candida spp. allows the prediction of subsequent severe candidosis in surgical patients. The aim of this study was to assess among 13 selected variables, those that would best predict the perioperative variation of the colonization index (CI) of Candida spp. in cardiovascular surgical patients. The colonization index took into account the number of sites colonized and the density of growth. The results showed that 56.8% of our patients were colonized perioperatively. A total of 116 isolates were identified and Candida albicans accounted for 76.7% of the strains. Among the patients who developed post-surgical Candida infections, 57.1% had an increase of the CI early after the operation. By univariate analysis, three factors were significantly associated with an increase of the CI in patients after surgery; sex (female), the duration of central intravascular catheterization and the length of stay in the surgical intensive care unit (SICU). Epidemiological data could help predict those patients who are at risk of developing Candida infections.
Aged↗
Perioperative variation in phagocytic activity against Candida albicans measured by a flow-cytometric assay in cardiovascular-surgery patients.
Candidiasis is an opportunistic fungal infection that frequently occurs following modifications of host defenses. Major surgery can be responsible for such alterations, and therefore it increases the risk of fungal infection. The purpose of this study was to evaluate the perioperative impairment of leukocyte function in patients after cardiovascular surgery by measuring the phagocytic activity against Candida albicans by a flow-cytometric method. The average postsurgical decrease in phagocytosis in our patients was 11.4%. By univariate analysis, three factors, all related to antibiotic therapy, were significantly associated with an important decrease in phagocytosis; the use of antimicrobial therapy before surgery, the number of different antibiotics taken, and the length of antibiotic treatment. The results of our study showed that the use of antibiotics in patients undergoing cardiovascular surgery alters the normal phagocytic activity of the host immune system against C. albicans and that flow cytometry is a rapid and simple technique that helps in early identification of patients at high risk for Candida infections. The mechanisms by which surgery and antibiotics decrease phagocytosis remain to be elucidated.
Adult↗
[Cardiac surgery in Quebec: Do we have too many centers? Too many surgeons? Too many patients?].
OBJECTIVE: In restructuring the Quebec health care system with hospital budget cuts, salary ceiling of physicians and a small number of practising cardiac surgeons, the future of this specialty needs to be defined beyond individual self-interest. To evaluate the actual situation and to suggest changes that will improve surgical care delivery in cardiac surgery, surgeon and centre case loads in the province of Quebec were reviewed. DESIGN: Retrospective study. SETTING: Province of Quebec, 1994. PATIENTS: Patients who underwent coronary artery bypass grafting in 1994. RESULTS: The rate of coronary bypass grafting in Quebec was similar to that in Canada as a whole. The number of patients undergoing coronary artery bypass grafting increased at a rate of 6.5%/year during the five years preceding 1994, when operations numbered 5000. Thus, 7000 procedures will be performed in the year 2000 if the actual increase remains similar. There are 12 centres performing cardiac surgery in Quebec, with one centre/600,000 population and 3.4 surgeons/centre, compared with one centre/800,000 population and 3.7 surgeons/centre in Canada. In the year 2000, to accommodate 7000 cases, 18 centres will be required for a minimal case load per centre (300 cases/centre) or nine centres for an optimal case load per centre (700 cases). CONCLUSION: Each centre of cardiac surgery should perform an optimal volume of cases to achieve maximal use of human and physical resources devoted to the care of cardiac surgical patients in the province of Quebec.
Cardiac Care Facilities↗
Myocardial distribution of cardioplegia administered by antegrade and retrograde routes to ischemic myocardium.
OBJECTIVE: To study the distribution of a cardioplegic solution delivered by antegrade and retrograde routes to ischemic myocardium. Retrograde administration has been suggested to improve protection of the ischemic myocardium. However, there are insufficient data on perfusion of ischemic and necrotic zones by the retrograde route. DESIGN: A laboratory study in dogs. METHOD: In 12 dogs, 500 mL of hyperkalemic crystalloid cardioplegia containing 0.5 mCi of thallium-201 was injected antegradely or retrogradely through the coronary sinus after 3 hours of occlusion and 2 hours of reperfusion of the left anterior descending coronary artery. Myocardial distribution of the cardioplegic solution was measured by computer planimetry in the normally perfused zone, in the ischemic area and in the necrotic zone. RESULTS: The mean (and standard deviation) area at risk of ischemia (% of the left ventricle) delimited by Evans blue perfusion was smaller in dogs receiving a retrograde injection than in those receiving an antegrade injection (34% [3%] v. 42% [4%], p = 0.15). The infarct size (% of the area at risk indicated by triphenyltetrazolium dye) averaged 25% (11%) and 20% (7%) respectively (p = 0.36). The ratio of thallium-201 activity in ischemic to normal myocardium averaged 76% (13%) in the retrograde and 89 (12%) in the antegrade groups (p = 0.75). The ratio of thallium activity of infarct to normal myocardium averaged 56% (8%) in the retrograde group and 93% (19%) in the antegrade group (p = 0.18). Large areas of hypoactivity in the left ventricular myocardium were noted on scintigraphic imaging in all dogs that received retrograde perfusion. CONCLUSIONS: The retrograde injection of cardioplegia through the coronary sinus does not improve the distribution of cardioplegic solution in the acutely ischemic myocardial area nor in the zone of acute infarction in the dog. Because some cells may remain viable in the border zone and into the necrotic area, retrograde cardioplegia may result in suboptimal protection and incomplete prevention of further damage to the myocardium.
Animals↗
Comparison of Neoral and Sandimmune cyclosporine for induction of immunosuppression after heart transplantation.
OBJECTIVE: To compare the efficacies of Neoral cyclosporine (N-CSA [Sandoz]) and Sandimmune cyclosporine (S-CSA [Sandoz]) in induction of immunosuppression immediately after heart transplantation. DESIGN: A prospective and a retrospective cohort. SETTING: Patients who underwent heart transplant operations at the Montreal Heart Institute, Montreal, Quebec. PATIENTS: To evaluate the results of both formulations of cyclosporine (CSA), a cohort of 20 consecutive patients who underwent heart transplant operations between 1994 and 1995, and who were administered N-CSA, azathioprine, prednisone and intravenous CSA (10 patients) or rabbit antithymocyte globulin (RATG) (10 patients) were compared with 21 patients who underwent heart transplant operations between 1993 and 1994, and were treated with RATG, S-CSA, azathioprine and prednisone. Preoperative patient characteristics were similar in all groups. RESULTS: There were no significant differences in daily CSA doses after the fourth day following transplantation. Higher trough levels of CSA were observed during the first four days, from days 12 to 14 and one month after transplantation in the two groups that were administered N-CSA. Serum levels of creatinine were significantly higher three to five days after transplantation in both groups who received N-CSA. Creatinine levels were also higher between days 13 and 14 in patients who received N-CSA and intravenous CSA. Oral administration of N-CSA was stopped temporarily in two patients (20%) who received intravenous CSA because of a sudden decrease in urine output and rise in serum creatinine. Three months after transplantation actuarial freedom rate from acute rejection averaged 33 +/- 10% in the S-CSA group, 10 +/- 9% in patients treated with N-CSA and intravenous CSA and 24 +/- 15% in patients treated with N-CSA and RATG (P = 0.25). The risk (hazard) of early rejection was higher in the group that received intravenous CSA and N-CSA. CONCLUSIONS: While similar averaged doses of N- and S-CSA were administered early after transplantation, the use of N-CSA resulted in higher blood levels of CSA. N-CSA appears to be well absorbed early after cardiac transplantation, but renal toxicity remains a significant concern.
Administration, Oral↗
[Coronary artery bypass grafting without cardiopulmonary bypass: angiographic evaluation of a preliminary experience].
BACKGROUND: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass has been proposed to decrease morbid events related to the circuit and the blood pump. OBJECTIVE: To evaluate quantitatively coronary anastomoses with CABG without cardiopulmonary bypass. SETTING: Between February and December 1996, 19 patients underwent CABG, through a median sternotomy in 12 patients and an anterior minithoracotomy in seven patients. Twenty internal thoracic artery grafts and seven saphenous vein grafts were studied by quantitative angiography in the immediate postoperative period (4 +/- 2 days). Diameters of native coronary arteries and grafts were analyzed by computer. PATIENTS: Patients averaged 57 +/- 8 years of age, with triple vessel coronary disease in three patients, double vessel disease in nine patients and single vessel disease in seven patients. Twelve patients underwent a single thoracic artery graft to the left anterior descending artery and seven patients underwent a double graft to the anterior descending and the right coronary artery. RESULTS: Hospital stay averaged 5 +/- 2 days, operating time averaged 144 +/- 30 mins and ischemic occlusion of the left anterior descending coronary artery averaged 20 +/- 8 mins. Serum creatine kinase MB fraction averaged 11 +/- 7 U/L and 25 +/- 37 U/L, 1 and 24 h, respectively, after surgery. Diameter stenosis of the native coronary artery averaged 19 +/- 26% proximal to the anastomosis, 36 +/- 31% distal to the anastomosis and 27 +/- 32% at the anastomotic site of internal thoracic artery grafts. One native coronary artery distal to the anastomosis was occluded and an occluded anastomosis was reopened by percutaneous angioplasty 72 h after surgery. Saphenous vein grafted to the right coronary artery had only minimal stenosis at anastomotic sites. CONCLUSION: This initial experience with CABG without cardiopulmonary bypass suggests that adequate coronary anastomosis can be performed in selected patients.
Cardiopulmonary Bypass↗
International experience with the CardioWest total artificial heart as a bridge to heart transplantation.
As the number of potential heart donors remains constant and the number of potential recipients continuous to increase, the need for circulatory devices to bridge patients becomes more important. The CardioWest total artificial heart (TAH) is a pneumatic, implantable system that totally replaces the failing ventricles. It has been utilized worldwide as a bridge to heart transplantation in 79 patients. There were 73 males and six females who received the TAH. Currently three patients remain on the device waiting for transplantation. A total of 55 patients (70%) were transplanted of which 50 survived (91% of patients transplanted) and were discharged home. Idiopathic/dilated cardiomyopathy was the most common etiology followed by ischemic cardiomyopathy. The mean duration of implant was 34 days (range 0-186 days) and the mean age of the group was 45 years (range 16-62 years). Twenty-one patients died while on the device. Multiple organ failure was the major cause of death. There were a total of 255 complications in this group that included reoperation, bleeding, hepatic failure, renal failure, respiratory failure, neurologic events, thromboembolic events, infections, device malfunction, and fit complications. This represented a mean complication rate of three events per patient. The survival rate for the CardioWest TAH of 91% of the patients who reached transplantation is an improvement over that of the Symbion registry (55% of those transplanted) probably as a result of a better patient selection and better control of the coagulation system. These results are also comparable to those survival results obtained with other biventricular and left ventricular assist devices currently available.
Adolescent↗
Percutaneous transluminal angioplasty in coronary-internal thoracic-subclavian steal syndrome.
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Angioplasty, Balloon, Coronary↗