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Biomedical subjects

R J Shemin

Publications and source records attributed to R J Shemin.

At least 19 recordsLinked to original sources
PubMed1999

Coronary revascularization in diabetic patients: a comparison of the randomized and observational components of the Aypass Angioplasty Revascularization Investigation (BARI).

BACKGROUND: Patients with treated diabetes in the randomized-trial segment of the Bypass Angioplasty Revascularization Investigation (BARI) who were randomized to initial revascularization with PTCA had significantly worse 5-year survival than patients assigned to CABG. This treatment difference was not seen among diabetic patients eligible for BARI who opted to select their mode of revascularization. We hypothesized that differences in patient characteristics, assessed and unmeasured, together with the treatment selection in the registry, at least partially account for this discrepancy. METHODS AND RESULTS: Among diabetics taking insulin or oral hypoglycemic drugs at entry, angiographic and clinical presentations were comparable between randomized and registry patients. However, more registry patients were white, and registry diabetics tended to be more educated and more physically active and to report better quality of life. Procedural characteristics and in-hospital complications were comparable. The 5-year all-cause mortality rate was 34.5% in randomized diabetic patients assigned to PTCA versus 19.4% in CABG patients (P=0.0024; relative risk [RR]=1.87); corresponding cardiac mortality rates were 23.4% and 8.2%, respectively (P=0.0002; RR=3.10). The CABG benefit was more apparent among patients requiring insulin. In the registry, all-cause mortality was 14.4% for PTCA versus 14.9% for CABG (P=0.86, RR=1.10), with corresponding cardiac mortality rates of 7.5% and 6. 0%, respectively (P=0.73; RR=1.07). These RRs in the registry increased to 1.29 and 1.41, respectively, after adjustment for all known differences between treatment groups. CONCLUSIONS: BARI registry results are not inconsistent with the finding in the randomized trial that initial CABG is associated with better long-term survival than PTCA in treated diabetic patients with multivessel coronary disease suitable for either surgical or catheter-based revascularization.

Aged↗
PubMed1999

Prolongation of rat skin and cardiac allograft survival by low molecular weight heparin.

BACKGROUND: We have previously reported that very low doses of low molecular weight heparin compounds (LMWH) inhibit a variety of T-cell-mediated reactions by down-regulation of TNF-alpha production. This study tested the efficacy of LMWH in organ transplantation. METHODS: Skin and heterotopic heart transplantations were performed between recipient Wistar rats and donor BN rats. Two doses of LMWH were given sc, 1 and 20 micrograms, each in three protocols, with day of grafting as Day 0: (A) Daily: -1, 0, 1 ellipsis, (B) Late Weekly: -1, 6, 13 ellipsis, and (C) Early Weekly: -7, 0, 7 ellipsis. Doses and schedules were selected based on efficacy in autoimmune models. Skin graft rejection was defined by complete separation of the graft, and heart transplant rejection was defined as cessation of heartbeat. RESULTS: Treatment with 1 microgram (26.8 +/- 2.0 days) and 20 micrograms (24.5 +/- 2.3 days) of LMWH using the Early Weekly protocol significantly prolonged skin allograft survival compared to controls (17.8 +/- 4.4 days), P < 0.001 for both, whereas other protocols did not. Compared to controls (8.3 +/- 1.4 days), treatment with both 1 and 20 micrograms of LMWH using all three protocols significantly prolonged cardiac allograft survival. The efficacy, however, varied considerably. Increase in graft survival ranged from 18% (1 microgram, Daily, 9.8 +/- 0.7 days, P = 0.02) to more than twofold (20 micrograms, Early Weekly, 20.8 +/- 5.5 days, P < 0.001) according to the dose and schedule of LMWH. CONCLUSIONS: Treatment with very low doses of nonanticoagulant LMWH preparations having anti-TNF-alpha activity significantly prolongs rat skin and cardiac allograft survival in a dose- and schedule-dependent manner.

Animals↗
PubMed1999

Decreased incidence of arterial thrombosis using heparin-bonded intraaortic balloons.

BACKGROUND: This experimental study sought to determine whether heparin-bonding of intraaortic balloons (IAB) would decrease the incidence of arterial thrombosis in the absence of systemic heparinization. METHODS: In 25 adult pigs, a 9F, 40-mL IAB was inserted into the femoral artery and positioned just below the takeoff of the left subclavian artery for 9 hours. Five animals received systemic heparin, 10 animals had no heparin, and another 10 animals received no heparin but the IAB was heparin-bonded (Duraflo II). Thrombus formation was assessed using a numerical scoring system (0 = no thrombosis to 3 = thrombus >5 cm or evidence of luminal compromise). RESULTS: Animals receiving heparin and heparin-bonded IAB had no thrombus formation around the IAB (mean +/- SE; 0 +/- 0.00 heparin versus 1.55 +/- 0.29 no heparin versus 0 +/- 0.00 heparin-bonded; p < 0.005), at the insertion site (0 +/- 0.00 heparin versus 1.55 +/- 0.29 no heparin versus 0 +/- 0.0 heparin-bonded; p < 0.005), and in the distal femoral artery (0 +/- 0.00 heparin versus 2.00 +/- 0.23 no heparin versus 0 +/- 0.00 heparin-bonded; p < 0.005). CONCLUSIONS: Heparin-bonding of the IAB significantly decreases thrombus formation in the absence of systemic heparinization.

Animals↗
PubMed1999

First report of the Port Access International Registry.

BACKGROUND: For minimally invasive cardiac operations to be widely applicable, the risks must be equivalent to those of standard open-chest operations. This study analyzed the outcomes of patients recorded in the multicenter Port Access (PA) International Registry to establish operative risks. METHODS: Data were analyzed for intent to treat in 583 patients who underwent PA coronary artery bypass grafting (CABG), 184 who underwent PA mitral valve replacement, and 137 who underwent PA mitral valve repair at 121 centers. RESULTS: Port Access was attempted in 1,063 patients and completed in 1,004 (94%). The operative mortality rate was 1% for PA CABG, 3.3% for PA mitral valve replacement, and 1.5% for PA mitral valve repair. Perioperative morbidity was low in all categories: stroke = 1.1% to 3.6%, myocardial infarction = 0 to 1%, primary procedure reoperation = 0 to 0.7%, renal failure = 0.2% to 0.7%, multiorgan failure = 0 to 0.5%, and atrial fibrillation = 5% to 7.3%. CONCLUSIONS: Data on 1,063 patients from 121 centers demonstrate that PA CABG and PA mitral valve operations can be performed safely, with morbidity and mortality rates similar to those associated with open-chest operations. Further studies are indicated to establish the long-term efficacy of this method and to analyze its effect on recovery time.

Adult↗
PubMed1999

Effect of gender on postoperative outcomes and hospital stays after coronary artery bypass grafting.

BACKGROUND: Compared to men, women undergoing coronary artery bypass grafting appear to have a higher morbidity and mortality, particularly in the perioperative period. This study was designed to answer the questions of whether such differences in clinical outcomes between men and women still exist with improvements in surgical techniques and determine whether it is gender or associated comorbid conditions in women that lead to higher morbidity. METHODS: An analysis of a single center's contemporary experience (1994 to 1997) of 1,743 consecutive patients undergoing primary coronary artery bypass grafting was performed. Only reoperations were excluded. Data were collected prospectively and presented as mean +/- standard deviation (p<0.05). RESULTS: Women represented 30.0% of patients. Compared with men, women were older (68.4 versus 63.8 years; p<0.05), and had more urgent surgical interventions (70.0% versus 56.7%; p<0.05), a higher incidence of diabetes (42.1% versus 26.7%; p<0.05), hypertension (82.0% versus 73.9%; p<0.05), lower body surface area (1.73+/-0.18 m2 versus 2.03+/-0.19 m2; p<0.05), and hematocrit (31.7%+/-3.9% versus 36.2%+/-3.9%; p<0.05). Ejection fraction, incidence of previous myocardial infarction, chronic obstructive pulmonary disease, left main (LM) disease, renal insufficiency, extent of coronary disease, and preoperative intraaortic balloon pump were similar. Women received fewer arterial grafts (91.0% versus 95.5%; p<0.05) and distal anastomoses (3.31+/-0.88 versus 3.49+/-0.94 p<0.05). Despite these differences, there were no statistical differences in the incidence of postoperative death (1.5% versus 1.0%), myocardial infarction (0.6% versus 0.6%), or cerebrovascular accident/transient ischemic attack (1.1% versus 0.4%) between men and women. Women had a higher inotropic support (10.2% versus 4.4%; p<0.05) and longer hospital stays (7.3+/-5.7 days versus 6.3+/-4.2 days; p<0.05). Using multivariate analysis, female gender was not an independent predictor of death or postoperative complications but was a predictor of length of hospital stay, use of arterial grafts, and extent of coronary revascularization. CONCLUSIONS: After accounting for differences in their risk variables, the incidences of death, perioperative myocardial infarction and cerebrovascular accident/ transient ischemic attack after coronary artery bypass grafting in women and men were not statistically significant. Perioperative complications are related to comorbid risk factors but not to female gender itself. Further studies are warranted.

Age Factors↗
PubMed1999

Improved clinical outcomes after operation of the proximal aorta: a 10-year experience.

BACKGROUND: This study evaluated the impact of recent advances (particularly noninvasive diagnosis, retrograde cerebral perfusion, heparin-bonded circuits, and use of collagen-impregnated grafts and antifibrinolytic agents) on clinical outcomes of patients undergoing proximal aortic operations. METHODS: One hundred eight consecutive patients undergoing 111 proximal aortic operations over 10 years were studied. The cohort was divided into two groups: early, 1987 to 1993 and late, 1994 to 1997. RESULTS: Baseline patients profiles, indications for operation (aneurysm, 66 patients; dissection, 45 patients), priority of the operation, and surgical procedures were comparable for both groups. Mortality and morbidity for the entire cohort were 13.5% (15 of 111) and 66% (73 of 111), respectively. Compared with the early group, the late group was characterized by significantly higher use of noninvasive diagnostic modalities (69% versus 10%), exclusive use of heparin-bonded circuits and collagen-impregnated grafts (100% versus 0% for both), use of antifibrinolytic agents (79% versus 8%), and the introduction of retrograde cerebral perfusion (43% versus 0%) (p<0.00001 for all). These changes in practice were associated with a substantial decrease in operative mortality (26% [13 of 49] versus 3% [2 of 62], p = 0.001), overall morbidity (77% [38 of 49] versus 56% [35 of 62], p = 0.02), blood transfusions (55.6+/-48 donor units versus 29.3+/-35 donor units, p = 0.003), and a shorter hospital stay (21.6+/-31 days versus 12.1+/-15 days, p = 0.07). Average long-term follow-up for 99% (107 of 108) of patients was 29.6+/-30 months (1 to 120 months). Ten-year actuarial survival was 57.3%+/-8% with 93% being in New York Heart Association functional class I or II. CONCLUSIONS: Recent advances, particularly noninvasive diagnosis and improved operative management, have led to a substantial reduction in mortality and morbidity after proximal aortic operation. Improved short- and long-term outcomes were achieved both in acute dissection and aneurysm procedures, although patients remain at risk for long-term distal aortic complications.

Adult↗
PubMed1999

Nitroglycerin is superior to diltiazem as a coronary bypass conduit vasodilator.

BACKGROUND: Recent reports of improved radial artery patency have been attributed, in part, to routine use of diltiazem to prevent vasospasm. However, diltiazem is costly, and its use may be associated with negative inotropic and chronotropic side effects. This study compares the vasodilatory properties of diltiazem to those of nitroglycerin. METHODS: In vitro, with the use of organ chambers, the vasodilatory properties of diltiazem and nitroglycerin were compared in matched segments of radial artery, internal thoracic artery, and saphenous vein that were harvested from the same patients (n = 11). The vasodilatory response of the radial artery to intravenous diltiazem or nitroglycerin was compared in vivo (n = 10) with the use of ultrasonographic measurements of radial artery diameter. RESULTS: The maximum relaxation of radial artery (100% +/- 4%), internal thoracic artery (96% +/- 4%), and saphenous vein (100% +/- 3%) to nitroglycerin were significantly greater than the response to diltiazem (33% +/- 6%, 22% +/- 7%, and 34% +/- 5%, respectively; P <.001). The thromboxane mimetic, U46619, induced radial artery spasm with a median effective concentration of 3.7 +/- 0.8 nmol/L. Physiologic concentrations of nitroglycerin (0.1+/- micromol/L) significantly inhibited the radial artery response to U46619 (median effective concentration, 6.2 +/- 1.1 nmol/L; P =.046), whereas diltiazem (1 micromol/L) did not (median effective concentration, 3.7 +/- 0.8 nmol/L; P =.64). In vivo, nitroglycerin increased radial artery diameter 22% +/- 3%, which was significantly greater than diltiazem (3% +/- 0.5%; P =.001). CONCLUSION: Nitroglycerin is a superior conduit vasodilator and is more effective in preventing graft spasm than diltiazem. Nitroglycerin should be strongly considered as the drug of choice to prevent conduit spasm after coronary bypass grafting.

Adult↗
PubMed1998

Effect of anticoagulation protocol on outcome in patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits.

BACKGROUND: We have demonstrated that the use of heparin-bonded cardiopulmonary bypass circuits (HBCs) combined with a lower anticoagulation protocol as an adjunct to an integrated blood conservation strategy decreases the incidence and magnitude of homologous transfusion and improves clinical outcome in patients undergoing primary coronary artery bypass grafting. It is not known whether it is the lower anticoagulation protocol that influences outcome in patients treated with HBCs. Furthermore, the thrombogenic risk of using lower anticoagulation with HBCs still is debated. METHODS: To answer these questions, a prospective randomized study was conducted in which 244 patients undergoing primary coronary artery bypass grafting were treated with HBCs and randomized to undergo either a full (activated clotting time, > 450 seconds) or a lower (activated clotting time, > 250 seconds) anticoagulation protocol. In addition to clinical outcome, levels of thrombin generation markers during and after cardiopulmonary bypass were assessed in a consecutive subset of 58 patients (full anticoagulation profile = 28, lower anticoagulation profile = 30) by measuring thrombin-antithrombin complexes and prothrombin fragment 1.2. Levels of these markers also were correlated with the activated clotting time during cardiopulmonary bypass. RESULTS: Preoperative and intraoperative risk profiles and other characteristics were similar in both groups, with more than 60% of patients undergoing nonelective operation. Compared with the full anticoagulation protocol group, patients in the lower anticoagulation protocol group were less likely to require blood products (24.2% versus 35.8%, respectively; p = 0.047) and received substantially fewer homologous donor units (0.50 +/- 0.92 versus 1.08 +/- 2.10 U, respectively; p = 0.005). Clinical outcomes were uniformly outstanding (but similar) in both treatment groups, with a modest reduction in the length of the hospital stay in the lower anticoagulation protocol group (5.26 +/- 1.23 versus 5.63 +/- 1.73 days, respectively; p = 0.05). The use of HBCs with a lower anticoagulation protocol was not associated with any adverse clinical events. Thrombin generation increased during cardiopulmonary bypass in both treatment groups, but was unrelated to the anticoagulation protocol or the activated clotting time (r2 = 0.03). No differences between the full and lower anticoagulation protocol groups were noted in the number of microemboli detected by transcranial Doppler analyses during cardiopulmonary bypass (n = 40) or in the postoperative neurologic and neuropsychologic outcomes (n = 30). CONCLUSIONS: This study definitively demonstrates that, when used appropriately, patients who are treated with HBCs and a lower anticoagulation protocol have a lower incidence and magnitude of homologous transfusion and are not at any added risk for clinical, hematologic (thrombin-antithrombin complex and fragment 1.2 measurements), or microscopic (transcranial Doppler analyses) thromboembolic complications or for neurologic or neuropsychologic deficits.

Aged↗
PubMed1998

Reduction of allogeneic blood transfusions after open heart operations by lowering cardiopulmonary bypass prime volume.

BACKGROUND: Despite recent advances in blood conservation techniques, up to 30% to 80% of patients undergoing open heart operations require allogeneic blood transfusions. A prospective, randomized study was performed to test the effect of lowering cardiopulmonary bypass prime volume (as an additional component of an integrated blood conservation strategy) on clinical outcome and allogeneic blood transfusion. METHODS: One hundred fourteen patients undergoing open heart operations were randomized to either full prime (FP) volume (1,400 mL of Plasmalyte solution) or reduced prime (RP) volume (600 to 800 mL). The reduction of prime volume was achieved by slowly draining the cardiopulmonary bypass circuit into a cell-saving device before the initiation of bypass. Firm transfusion thresholds were observed. RESULTS: There were no significant differences between the groups with respect to baseline characteristics, body surface area, type and urgency of the procedures, perfusion technique, and hematologic profile. Mortality (FP, 1.7%; RP, 0%; p approximately 1.0) and overall morbidity (FP, 28.1%; RP, 22.8%; p = 0.53) were similar. However, transfusion requirements were significantly lower in the RP group: total donor exposure, 3.8 +/- 10.1 versus 1.0 +/- 2.4 units (p = 0.044); percentage of patients transfused, 54% (n = 31) versus 35% (n = 20) (p = 0.036). Twenty-four-hour chest tube drainage was similar: 455 +/- 223 mL for FP versus 472 +/- 173 mL for RP (p = 0.66). The lowest hematocrit on bypass was significantly higher in the RP group: 29.3% +/- 4% versus 26.3% +/- 5.3% (p = 0.009). CONCLUSIONS: Lowering cardiopulmonary bypass prime volume resulted in a significant decrease in allogeneic blood product use. Because postoperative 24-hour chest tube drainage was similar in both groups, and hematocrit during bypass was higher in the RP group, the reduction in allogeneic blood transfusions appears to be related to a decrease in prime-induced hemodilution. This technique is effective, simple, and safe. It therefore should be strongly considered for patients undergoing operations using normothermic or near-normothermic cardiopulmonary bypass who are at high risk for allogeneic blood transfusion.

Aged↗
PubMed1998

Soluble complement receptor type I limits damage during revascularization of ischemic myocardium.

BACKGROUND: This study was undertaken to determine whether suppression of complement activation with soluble human complement receptor type I reduces myocardial damage during the revascularization of ischemic myocardium. METHODS: In 20 pigs, the second and third diagonal coronary arteries were occluded for 90 minutes, followed by 45 minutes of cardioplegic arrest and 180 minutes of reperfusion. In 10 pigs, soluble human complement receptor type I (10 mg/kg) was infused over 30 minutes before the period of coronary occlusion; 10 other pigs received no soluble human complement receptor type I. Complement activation was measured by total hemolytic complement activity (expressed as a percentage of preischemic values). Ischemic damage was assessed by changes in myocardial tissue pH, wall motion scores (range, 4=normal to -1=dyskinesia), and infarct size (area of necrosis versus area at risk). RESULTS: After 180 minutes of reperfusion, hearts treated with soluble human complement receptor type I had significantly less complement activation than nontreated hearts (1.1%+/-0.09% versus 7.8%+/-0.04%, respectively; p < 0.002), less myocardial acidosis (-0.41+/-0.03 versus -0.72+/-0.03, respectively; p < 0.0001), higher wall motion scores (3.1+/-0.09 versus 1.67+/-0.16, respectively; p < 0.0001), and smaller infarct size (24.6%+/-2.0% versus 41%+/-1.3%, respectively; p < 0.0001). CONCLUSIONS: Complement inhibition with soluble human complement receptor type I significantly limits ischemic damage during the revascularization of acutely ischemic myocardium.

Acidosis↗
PubMed1998

Comparison of risk profile and outcomes in patients undergoing surgical and catheter-based revascularization.

BACKGROUND: The effects of the randomized revascularization trials and improved strategies and techniques for coronary artery bypass graft (CABG) surgery and percutaneous transluminal catheter-based revascularization (PTCR) on current patient selection and clinical outcomes are unknown. METHODS: We evaluated a concurrent, contemporary (1995 to 1997), and consecutive group of patients undergoing CABG (n = 982) or PTCR (n = 939) in a single institution that participated in the Bypass Angioplasty Revascularization Investigation (BARI) trial. Results are presented as percent or mean +/- SD. Compared to PTCR, patients undergoing CABG were older (66.2+/-10.7 vs. 62.0+/-11.8 years, p<0.05) with a higher incidence of hypertension (73.3% vs. 52.4%, p<0.05), diabetes (32.5% vs. 23.1%, p<0.05), active smoking (67.8% vs. 27.2%, p<0.05), prior myocardial infarction (MI)(66.8% vs. 28.5%, p<0.05), peripheral vascular disease (19.8% vs. 7.7%, p<0.05), prior cerebrovascular accident (CVA)/transient ischemic attack (TIA) (6.4% vs. 2.8%, p<0.05), and a lower ejection fraction (48.7%+/-14.5% vs. 55.3%+/-11.7%, p<0.05). The presenting functional class and incidence of female gender were similar for both revascularization strategies. RESULTS: Compared to patients undergoing CABG, those undergoing PTCR were more likely to have single or two vessel coronary artery disease (88.6% vs. 23.1%, p<0.001) and had fewer vessels revascularized per patient (1.08+/-0.30 vs. 3.5+/-0.98, p<0.001). Outcomes were comparable for CABG and PTCR with a similar incidence of death (1.0% vs. 0.9%, NS), renal insufficiency (0.7% vs. 0.6%, NS), and CVA/TIA (0.9% vs. 0.3%, NS). Patients undergoing CABG had a higher incidence of pulmonary complications (5.2% vs. 1.0%, p<0.05), a lower incidence of periprocedural MI (1.1% vs. 4.1%, p<0.05) and major complication (5.9% vs. 9.4%, p<0.05), but longer hospital stays (6.5+/-5.1 vs. 3.1+/-2.6 days, p<0.05). CONCLUSIONS: Despite higher clinical and angiographic risk profiles in patients undergoing CABG, clinical results, morbidity, and mortality were comparable to those of PTCR. With evolving techniques, continued reevaluation of indications and outcomes are necessary.

Aged↗
PubMed1997

Repair of left ventricular aneurysm: long-term results of linear repair versus endoaneurysmorrhaphy.

BACKGROUND: Recently, endoaneurysomorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques. METHODS: Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair. RESULTS: The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 +/- 0.08 versus 0.30 +/- 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 +/- 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 +/- 0.64 versus 0.18 +/- 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair (p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 +/- 0.11 versus 0.27 +/- 0.11; p = 0.90), left ventricular volume (171.6 +/- 59.1 versus 169.9 +/- 54.4 mL; p = 0.94), and sphericity index (0.61 +/- 0.09 versus 0.61 +/- 0.12; p = 1.0). CONCLUSIONS: Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.

Case-Control Studies↗
PubMed1997

Heparin-bonded circuits decrease myocardial ischemic damage: an experimental study.

BACKGROUND: Heparin-bonded cardiopulmonary bypass circuits reduce complement activation, but their effect on myocardial function is unknown. This study was undertaken to determine whether heparin-bonded circuits reduce myocardial damage during acute surgical revascularization. METHODS: In 16 pigs, the second and third diagonal vessels were occluded with snares for 90 minutes followed by 45 minutes of cardioplegic arrest and 180 minutes of reperfusion with the snares released. During the period of coronary occlusion, all animals were placed on percutaneous bypass followed by standard cardiopulmonary bypass during the periods of cardioplegic arrest and reperfusion. In 8 pigs, heparin-bonded circuits were used, whereas 8 other pigs received nonbonded circuits. RESULTS: Animals treated with heparin-bonded circuits had the best preservation of wall motion scores (3.5 +/- 0.3 versus 2.3 +/- 0.2; 4 = normal to -1 = dyskinesis; p < 0.05), least tissue acidosis (change in pH = -0.31 +/- 0.02 versus -0.64 +/- 0.08; p < 0.05), smallest increase in lung H2O (1.7% +/- 0.7% versus 6.1% +/- .5%; p < 0.05), and the lowest area of necrosis/area of risk (20.3% +/- 2.2% versus 40.4% +/- 1.6%; p < 0.05). CONCLUSIONS: We conclude that heparin-bonded circuits significantly decrease myocardial ischemic damage during acute surgical revascularization.

Acid-Base Equilibrium↗
PubMed1997

Factors influencing mortality after emergency coronary artery bypass grafting for failed percutaneous transluminal coronary angioplasty.

BACKGROUND: Emergency coronary artery bypass grafting after failed percutaneous transluminal coronary angioplasty is associated with increased mortality. METHODS: From 1981 through 1995, 117 patients at our institution underwent emergency coronary artery bypass grafting after failed percutaneous transluminal coronary angioplasty, with an in-hospital mortality rate of 13.6%. Univariate and multivariate analyses were used to identify the factors that influenced the risk of death. RESULTS: Univariate analysis revealed that patients who died more often were women and had chronic renal failure, lower ejection fractions, and more diffuse coronary artery disease; less often received an internal mammary artery graft or an antegrade perfusion catheter; required inotropic support in the cardiac catheterization laboratory; and experienced myocardial infarction. Multivariate analysis demonstrated that the need for inotropic support in the cardiac catheterization laboratory was the best predictor of perioperative death. CONCLUSIONS: Patients with a reduced ejection fraction in whom percutaneous transluminal coronary angioplasty fails, antegrade perfusion does not produce a response, and myocardial infarction occurs are more likely to die after coronary artery bypass grafting. The risk appears to be highest for patients who require inotropic support in the cardiac catheterization laboratory.

Analysis of Variance↗
PubMed1997

Glucose-insulin-potassium solutions enhance recovery after urgent coronary artery bypass grafting.

OBJECTIVE: This prospective, randomized, clinical study was undertaken to determine whether glucose-insulin-potassium solutions would benefit patients undergoing coronary artery bypass grafting because of unstable angina. METHODS: The study group consisted of 30 patients with unstable angina who required coronary artery bypass grafting. In 15 patients, glucose-insulin-potassium solution (30% dextrose in water; K+, 80 mEq/L: regular insulin, 50 units) was given intravenously at 1 ml/kg per hour after induction of anesthesia and administration continued for 12 hours after aortic unclamping. Fifteen patients in a separate group received 5% dextrose in water intravenously at 50 ml/hr. RESULTS: Patients treated with glucose-insulin-potassium solution had higher cardiac indices (2.8 +/- 0.1 vs 2.0 +/- 1 L/min per square meter; p < 0.001), lower inotrope scores (0.06 +/- 0.01 vs 0.46 +/- 0.19; p = 0.041), and less weight gain (6.4 +/- 9 vs 11.6 +/- 1.1 pounds; p < 0.001) and had shorter times of ventilator support (8.3 +/- 0.6 vs 14.2 +/- 0.2 hours; p = 0.003). They had a significantly lower incidence of atrial fibrillation (13.3% vs 53.3%; p = 0.020) and had shorter stays in the intensive care unit (14.8 +/- 1.3 vs 31.6 +/- 5.2 hours; p = 0.002) and in the hospital (6.0 +/- 0.4 vs 8.0 +/- 0.7 days; p = 0.010). CONCLUSIONS: We conclude that glucose insulin-potassium therapy enhances myocardial performance and results in faster recovery from urgent coronary artery bypass grafting.

Adult↗
PubMed1997

Aneurysmal coronary artery disease. Atherosclerotic coronary artery ectasia or adult mucocutaneous lymph node syndrome (Kawasaki's disease)?

A 46-year-old white man presented with a history of multiple myocardial infarctions since the age of 32. Coronary angiography demonstrated severe aneurysmal coronary artery disease. Four-vessel coronary artery bypass grafting (CABG) using bilateral internal mammary arteries and the left radial artery was successfully performed. The differential diagnosis of early onset adult aneurysmal coronary artery disease is discussed, with emphasis on Kawasaki's disease and atherosclerotic coronary artery ectasia. When CABG is indicated, total arterial revascularization should be attempted.

Coronary Aneurysm↗