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PubMedDate not supplied

Robotically enhanced coronary artery bypass surgery.

BACKGROUND: Robotically enhanced telemanipulation surgery is a fast developing technique which allows totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart as well as arrested heart. METHODS AND RESULTS: Between December 2002 and February 2004, 125 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system (Intuitive Surgical Inc., California). Eleven patients underwent totally endoscopic coronary artery bypass surgery. Of them 9 were done on beating heart while 2 were done on arrested heart. One hundred and fourteen patients had endoscopic takedown of internal mammary artery followed by minimally invasive direct coronary artery bypass in 63 patients and left anterolateral thoracotomy in 51 patients. The internal mammary artery mobilization time was 42 min (35-74 min) while the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. In 1 patient, the right internal mammary artery was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement done in patients undergoing minimally invasive direct coronary artery bypass was 64 ml/min. Seven patients required conversion to median sternotomy and coronary bypass surgery on beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was 1 in-hospital mortality. All 11 patients who underwent totally endoscopic bypass surgery had coronary angiography done at 3 months interval which showed 100% patency in 10 patients while one patient had 50% anastomotic narrowing for which coronary angioplasty was done in the same sitting. CONCLUSIONS: Using telematic technology, a complete endoscopic anastomosis is possible in both single vessel and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis as well.

Adult↗
PubMed2005

Cardiovascular component of the context signal memory in the crab Chasmagnathus.

Research on diverse models of memory in vertebrates demonstrates that behavioral, autonomic and endocrine responses occur together during fear conditioning. With invertebrates, no similar studies have been performed despite the extensive study of fear memory paradigms, as the context signal memory (CSM) of the crab Chasmagnathus granulatus, usually assessed by a behavioral parameter. Here, we study the crab's CSM, considering both the behavioral response and the concomitant neuroautonomic adjustments resulting in a heart rate alteration. Results show that upon the first presentation of the visual danger stimulus, a heart arrest followed by bradycardia is triggered together with a conspicuous escape response. The latter declines throughout training, while heart arrests become sporadic and bradycardia tends to deepen along the session. At test, 24 h after training, the outcome clearly contrasts with that shown at training, namely, stimulus presentation in the same context induces lower escape, no heart arrests and quick suppression of bradycardia. These results support the view that the same memory process brings about the changes in both responses. High escape, heart arrest and bradycardia are considered three parameters of the unconditioned response while minor escape, no heart arrests and bradycardia attenuation are three parameters of the learned response.

Animals↗
PubMed1989

Cardiogenic mixing: mechanisms and experimental evidence in dogs.

Cardiogenic mixing was studied in seven anaesthetized closed-chest dogs undergoing mechanical ventilation by comparing single-breath washout of two poorly soluble inert gases of widely differing diffusivities (helium (He) and sulphur hexafluoride (SF6)) in normal conditions with the heart beating (control), and during reversible temporary myocardial arrest (heart arrest). Cardiac arrest of approximately 20 s duration was induced repeatedly (8-15 times) by intracoronary injection of acetylcholine (approximately 35 mg) facilitated by a non-occluding 7-French gauge angiographic catheter maintained in the left coronary artery. After equilibration of lung gas with 1% helium and 1% SF6, single breath, constant flow expirograms were recorded in the tracheal tube by mass spectrometry after inspiration of test gas-free air. Series deadspace (VD) and relative alveolar slope (S) (increment of expired partial pressure, normalized to mixed expired-inspired partial pressure difference per increment of expired volume (S = (delta P/(PE-P1]/delta VE litre-1], were determined as indices for intrapulmonary gas mixing. The effects attributable to the action of the heart were quantified by the heart arrest: control ratio of VD and S, which were not significantly different from unity (P greater than 0.05) (VD: 0.95 (SD 0.05) for helium and 0.94 (0.07) for SF6; S:1.03 (0.10) for helium and 1.05 (0.14) for SF6. The He:SF6 ratios of VD and S (0.90 and 0.64, respectively), indicating diffusion dependent separation of gases, also were unaffected by the mechanical action of the heart. The data indicate that convective mixing by the mechanical action of the heart did not significantly enhance intrapulmonary mixing and transport.

Acetylcholine↗
PubMed1987

Controlled reperfusion following regional ischemia.

The ability to reverse acute coronary occlusion with fibrinolytic agents and percutaneous transluminal angioplasty has increased interest in the revascularization of ischemic myocardium. This study defines changes in global ventricular function, mass, and compliance during acute coronary occlusion and following reperfusion with blood in the beating and arrested heart. In 17 dogs on cardiopulmonary bypass, the proximal left anterior descending coronary artery was occluded for 45 minutes. In 12 dogs, flow was reestablished by releasing the coronary snare in the beating heart. In the other 5 dogs, the snare was released during a continuous 10-minute infusion of blood potassium cardioplegia in the arrested heart. Coronary occlusion resulted in significant decreases in stroke work index and left ventricular (LV) mass, but compliance was unchanged. Reperfusion in the beating heart increased LV mass compared with the values measured before ischemia (104 +/- 5 versus 95 +/- 5 gm; p less than 0.05) and decreased LV compliance (39 +/- 4 versus 53 +/- 4 ml at LV end-diastolic pressure of 8 mm Hg; p less than 0.05). In contrast, with blood cardioplegia-based reperfusion in the arrested heart, LV mass and LV compliance remained unchanged from control values. We conclude that revascularization of acutely ischemic myocardium in the beating heart further impairs LV function by increasing LV mass and decreasing compliance. This damage can be avoided by reperfusion with blood cardioplegia in the arrested heart.

Animals↗
PubMed1980

The mechanism of ammonia production and the effect of mechanical work load on proteolysis and amino acid catabolism in isolated perfused rat heart.

The effect of mechanical work load on net proteolysis, amino acid catabolism and ammonia production was studied in isolated perfused beating or K+-arrested hearts. Net proteolysis was about 16 mumol/g dry wt. during 1h and was not affected by the mechanical work. The combined catabolic rate of the major amino acids was 7.1 mumol/g dry wt. in the beating heart and 2.1 mumol/g dry wt. in the arrested heart during the 1 h experimental period. The main differences lay in the deamination of aspartate plus glutamate, which was inhibited by 60% during low energy consumption, and in net alanine synthesis, which was increased by 94%. The ammonia production plus its conversion into amide nitrogen was 9.2 and 3.4 mumol/g dry wt. in the beating and arrested heart respectively during 1 h. The decrease in the total adenine nucleotide pool during the 1 h perfusion was very low, 1.0 and 0.5 mumol/g dry wt. in the beating and arrested hearts respectively, and did not contribute significantly to ammonia production. Thus ammonia production is dependent on the cellular energy state, whereas net proteolysis is not. The maximal capacities of the purine nucleotide cycle and the glutamate dehydrogenase reaction towards deamination were much higher than the observed ammonia-production rates. The anaplerotic role of amino acid catabolism in the myocardium is discussed.

Adenine Nucleotides↗
PubMed1997

Lithium ion as a probe of Na+ channel activity in isolated rat hearts: a multinuclear NMR study.

The aim of this study was to analyze Na+ fluxes in whole perfused hearts using Li+ as a Na+ congener and 7Li-nuclear magnetic resonance as a detection method. Hearts were equilibrated for 32 min with 15 mM LiCl added to P1-free Krebs-Henseleit buffer (intracellular space (ICS) [Li+] = 21.5 +/- 3.4 mM). Li+ efflux was monitored using a Li(+)-free perfusate. The effects of drugs on Li+ efflux were studied by adding the compounds 4 min prior to initiating Li+ washout. 7Li-NMR spectra were collected every 2 min at 139.95 MHz. Li+ efflux was biphasic with rate constants (k +/- SD, min-1) of 0.5 +/- 0.1 (extracellular) and 0.09 +/- 0.01 (ICS). Li+ efflux from ICS was dependent on heart rate (HR): cardiac arrest produced by 1 mM lidocaine or 20 mM KCl reduced k to 1/3 of its control value (Lidocaine, 0.030 +/- 0.004; KCl, 0.035 +/- 0.003). Increasing concentrations of carbachol (0.2-3.0 microM) caused a gradual decrease in HR and revealed a linear relationship between k and HR. In KCl-arrested hearts the Na+ channel opener veratridine increased k by 60% (10 microM, 0.057 +/- 0.006). Dimethylamiloride did not affect k (10 microM, 0.024 +/- 0.006) in Lidocaine-arrested hearts. Bumetanide (30 microM, 0.094 +/- 0.013), nifedepine (0.33 microM, 0.088 +/- 0.009), Bay K8644 (0.1 microM, 0.080 +/- 0.002), 4-aminopyridine (1.5 mM, 0.076 +/- 0.006) and cromakalim (10 microM, 0.088 +/- 0.006) did not significantly affect either k or HR. Li+ efflux from myocytes in perfused rat heart is mediated mainly by voltage-dependent Na+ channels.

Animals↗
PubMed2006

On-pump beating-heart coronary artery bypass grafting for acute myocardial infarction.

BACKGROUND: The early results of emergent coronary artery bypass grafting by conventional operative method for acute myocardial infarction are reported to be poor. The purpose of this study is to evaluate on-pump beating-heart coronary artery bypass grafting for acute myocardial infarction. METHODS: Thirty-one patients with acute myocardial infarction underwent emergent surgery between January 1998 and June 2004 at Nayoro City General Hospital. In 16 patients, on-pump surgery was performed on the arrested heart, and in the other 15, on-pump surgery was performed on the beating heart. Early results were compared between the two groups. RESULTS: Preoperative and perioperative patient characteristics revealed no significant differences between the two groups. Although there was no statistically difference between the two groups, the early mortality rates of on-pump arrested-heart coronary bypass grafting (31.3%) was higher than that of on-pump beating-heart coronary bypass grafting (13.3%). Postoperatively, the creatine kinase myocardial band value for the on-pump beating-heart group was significantly lower than that for the on-pump arrested-heart group (221 +/- 200 IU/L versus 666 +/- 540 IU/L, p = 0.008). The incidence of postoperative acute renal failure was significantly higher in the on-pump arrested-heart group than in the on-pump beating-heart group (p = 0.034). The durations of ventilator use and inotropic agent use were longer in the on-pump arrested-heart group than in the on-pump beating-heart group, though the differences were not statistically different (p = 0.152, p = 0.223). CONCLUSIONS: On-pump beating-heart coronary artery bypass grafting has the possibility to eliminate intraoperative global myocardial ischemia and to be an acceptable surgical option for acute myocardial infarction associated with lower postoperative mortality and morbidity.

Acute Disease↗
PubMed1990

Leakage of cytoplasmic enzymes from rat heart by the stress of cardiac beating after increase in cell membrane fragility by anoxia.

The effects of spontaneous beating after anoxia and the pumping stress induced by a left ventricular balloon on the leakage of myocardial enzymes from the isolated perfused rat heart were investigated. Beating of the heart was arrested by perfusion with high-K+ medium. When the beating was arrested during reoxygenation after anoxia, the leakage of lactate dehydrogenase (LDH) was significantly lower than during reoxygenation with spontaneous cardiac beating. After changing from K+ arrest to spontaneous beating by perfusion with low-K+ medium during reoxygenation, the leakage of LDH increased markedly. Imposition of left ventricular wall stress on the K(+)-arrested heart by repetitive passive distension during aerobic perfusion and after 20 min and 60 min of anoxia caused LDH leakages of 1.0, 4.6 and 21.0 units/g in 30 min, respectively. Under this mechanical stress, the release of LDH as a percentage of its total myocardial activity coincided well with that of cytoplasmic aspartate aminotransferase (AST), while the percentage release of mitochondrial AST was much less. These results appeared to indicate that the leakage of cytoplasmic enzymes during reoxygenation is accelerated by cardiac beating because of fragility of the cell membranes developing during the preceding anoxia.

Adenosine Triphosphate↗
PubMed1991

Relation of myocardial protection to cardioplegic solution pH: modulation by calcium and magnesium.

The relationship between myocardial preservation and cardioplegic solution pH was assessed in isolated, perfused rat hearts. A base solution without calcium or magnesium and the same solution containing 0.2 mmol/L ionized calcium or 16 mmol/L magnesium or both ions were studied at several values of pH between 6.8 and 8.7. Hearts were arrested at 8 degrees C by multidose infusions of these bicarbonate-buffered solutions bubbled with oxygen and a varying percentage of carbon dioxide to control pH. Diastolic tone (left ventricular balloon) and adenosine triphosphate (ATP) depletion during arrest both increased as the cardioplegic solution became more alkaline. Calcium increased these effects of pH. Magnesium weakened the effect of pH on diastolic tone, maintained ATP at all pH levels, and inhibited the effects of calcium on the relationships of pH to diastolic tone and ATP. When data from all solutions were considered together, ATP depletion was shown to be linearly related to diastolic tone. Calcium depressed functional recovery (left ventricular developed pressure during reperfusion expressed as a percentage of its prearrest value) at all pH levels. With the other solutions, recovery was similar and best within a broad and relatively alkaline pH range. With the solution containing calcium and magnesium, at pH levels of 8.28 +/- 0.02, 7.87 +/- 0.03, 7.58 +/- 0.02, 7.41 +/- 0.01, 7.06 +/- 0.02, and 6.80 +/- 0.01, recovery at 5 minutes of reperfusion was 101.4% +/- 3.7%, 102.9% +/- 2.8%, 107.3% +/- 3.7%, 102.8% +/- 2.9%, 91.8% +/- 3.6%, and 94.3% +/- 3.5%, respectively. This effect of alkalinity was short-lived. Extreme alkalinity of the base, acalcemic solution produced the calcium paradox, as reported previously. Good preservation of ATP by the most acid solutions did not predict good functional recovery. Magnesium increased the persistence of frequent extrasystoles during early reperfusion, but the effect was attenuated by calcium. The data support the inclusion of magnesium in cardioplegic solutions, particularly when they contain calcium, show that cardioplegic solution pH can have major effects on the arrested heart, and suggest that a relatively alkaline pH may modestly benefit functional recovery.

Adenine Nucleotides↗
PubMed1990

Intraoperative assessment of regional myocardial perfusion using quantitative myocardial contrast echocardiography: an experimental evaluation.

To test the hypothesis that myocardial contrast echocardiography can be used to quantitate regional myocardial flow in the arrested heart at the time of delivery of cardioplegic solution, data were acquired in 13 dogs on cardiopulmonary bypass. Different degrees of stenosis were placed in random order on the left anterior descending coronary artery. For each stenosis, myocardial contrast echocardiography was performed by injecting sonicated albumin microbubbles into the cross-clamped aortic root at the time of delivery of cardioplegic solution. The resultant echocardiographic images were analyzed on an off-line computer. Background-subtracted time-intensity plots were generated, and an exponential function, f(t) = Ce-alpha t + De- beta t, was applied to each plot. Variables that reflected the total number of microbubbles entering the coronary artery bed, such as the area under the curve and the peak height of the curve, correlated best with radiolabeled microsphere-measured myocardial flow (r = 0.92 and r = 0.91, respectively). Variables that reflected the appearance of contrast microbubbles in the myocardium, such as the initial slope and the slope at 1 s, also had a good correlation with myocardial flow (r = 0.84 and r = 0.89, respectively). Variables that reflected the washout of contrast medium from the myocardium, such as the slope of the descending portion of the curve, had only a fair correlation with myocardial flow (r = 0.65). In six dogs, the technique of injecting contrast medium into the cross-clamped aortic root was also examined. Although continuous infusion of contrast medium produced smaller perturbations in mean aortic and distal left anterior descending artery pressures compared with a bolus injection (p less than 0.01), the correlation between the variables of the time-intensity curves and flow was equally close with both techniques. It is concluded that it is possible to quantitate myocardial flow by using myocardial contrast echocardiography at the time of delivery of cardioplegic solution in dogs on cardiopulmonary bypass. The implementation of this technique in humans might be useful in guiding the sequence of graft placement and thereby improving myocardial preservation during coronary artery bypass operations.

Animals↗
PubMed1998

Alkaline buffers for correction of metabolic acidosis during cardiopulmonary resuscitation with focus on Tribonat--a review.

A combined hypercarbic and metabolic acidosis develops during the low flow state of cardiac arrest treated with cardiopulmonary resuscitation. Several negative consequences of the acidosis have been demonstrated, two of the most important being reduced contractility of the ischaemic but still beating myocardium and impaired resuscitability of the arrested heart. Even though interventions to re-establish a spontaneous circulation should be the number one priority during cardiopulmonary resuscitation, attempts to treat the acidosis are often carried out in order to avoid the reported negative inotropic effect. Different alkaline buffers have been used, but it has been demonstrated over the years that such treatment may aggravate the situation due to a variety of deleterious side-effects of the buffers. A mixture of THAM, acetate, sodium bicarbonate and phosphate registered as Tribonat has been suggested as a suitable alternative to conventional buffer substances. The problems preceding the designation of Tribonat as well as studies evaluating its effects are reviewed in this article. Tribonat seems to offer a more well-balanced buffering without any major disadvantages compared with previously used alkaline buffers, even though improved survival has not been reported.

Acidosis↗
PubMed1997

Near-infrared monitoring of myocardial oxygenation during intermittent warm blood cardioplegia.

OBJECTIVE: This study was performed to examine the ability of near-infrared spectroscopy to monitor tissue oxygenation in the cardioplegically arrested heart and to assess myocardial oxygen metabolism during intermittent warm blood cardioplegia. METHODS: Using a three-wavelength near-infrared spectroscopy, we continuously measured myocardial tissue oxygen saturation and the tissue hemoglobin concentration during intermittent warm blood cardioplegia. Under normothermic cardiopulmonary bypass, 20 dogs received three 5-min periods of antegrade warm blood cardioplegia, interrupted by three 10-min episodes of ischemia in group 1 (n = 7), three 15-min episodes of ischemia in group 2 (n = 6), or three 20-min episodes of ischemia in group 3 (n = 7). RESULTS: Myocardial oxygen saturation during beating and ventricular fibrillation was 80 +/- 1 and 59 +/- 1%, respectively. Myocardial oxygen saturation rapidly increased to 82 +/- 1% at blood cardioplegic infusion and decreased to 58 +/- 1% 3 min after cardioplegic interruption. The time required to reach the peak oxygen saturation level decreased significantly at the second and third infusions compared to the first infusion in group 1, whereas the time increased significantly at the third infusion in groups 2 and 3. The slower rate of increase in oxygen saturation suggested reduced coronary vasodilator reserve due to microvascular abnormalities. Reperfusion ventricular fibrillation occurred in none of group 1, one of group 2 and three of group 3. CONCLUSIONS: Near-infrared spectroscopy is a useful method of continuously monitoring myocardial oxygenation and ischemia during warm heart surgery. Episodes of ischemia longer than 10 min during warm blood cardioplegia resulted in less-than-optimal myocardial preservation and should be avoided.

Analysis of Variance↗
PubMed2000

Total endoscopic computer enhanced coronary artery bypass grafting.

OBJECTIVE: In an effort to minimize access in coronary artery bypass (CAB) surgery, a total endoscopic approach using computer enhanced technology was developed. METHODS: By July 1999 the da Vinci telemanipulation system (Intuitive Surgical, Mountain View, CA) was used in 66 patients with coronary artery disease. In 12 patients undergoing routine coronary artery bypass grafting (CABG) (group 1) the internal thoracic artery (ITA) to left anterior descending artery (LAD) anastomosis was performed remotely using the system. In 32 patients (group 2) endoscopic dissection of the ITA was performed followed by a conventional minimally invasive direct coronary artery bypass (MIDCAB) operation. In 22 patients (group 3) the complete operation was performed endoscopically through 4 ports (total endoscopic coronary artery bypass, TECAB). Port-Access cardiopulmonary bypass with cardioplegic arrest was used for TECAB. RESULTS: In group 1 the time for performing the ITA to LAD anastomosis was 17 +/- 10 min. Mean graft flow was 38 +/- 25 ml/min. One anastomosis leaked and was repaired manually. In group 2 in 31/32 patients (96%) the ITA harvest was successfully performed with the system at mean of 61 +/- 27 min. There was a substantial learning curve associated with ITA take-down. In one patient a dissection caused insufficient free ITA graft flow which necessated additional vein grafting. Postoperative angiography demonstrated graft patency in all cases. In the TECAB group, the operation could be completed through four ports in 18 of the 22 patients (82%) with operating times in the range 220-507 min. In four patients, elective conversion to a minithoracotomy was required due to failure to identify the LAD (1), bleeding from the anastomosis (1), grafting of a diagonal branch (1) and torsion of the pedicle (1). One patient required reoperation for bleeding from an ITA side-branch. Median intubation time was 13 h and stay on ICU and hospitalization were 20 h and 7 days, respectively. A 3-month follow-up angiography revealed patent grafts in all TECAB patients. CONCLUSION: Endoscopic ITA harvesting and performing of arterial anastomoses can be safely performed with the da Vinci system. TECAB is possible on the arrested heart with good functional results. However, a substantial learning curve has to be overcome which is reflected in long operation times and an initial significant conversion rate.

Cardiopulmonary Bypass↗
PubMed1997

Right ventricle is protected better by warm continuous than by cold intermittent retrograde blood cardioplegia in patients with obstructed right coronary artery.

Preservation of the right-ventricular (RV) myocardium is a clinical challenge especially in patients with occluded right coronary artery, in whom antegrade cardioplegia cannot reach areas distal to the stenosis. Retrograde administration of cardioplegia has been thought to overcome the problem, but it has been blamed for inadequate distribution to the RV and possibly poorer functional recovery of this ventricle. Adapting the hypothesis that warm blood cardioplegia may offer better distribution and a more effective supply of oxygen to the arrested heart, we compared RV function in a randomised trial in patients with significant right and left coronary artery disease, after either warm continuous (warm group, n = 15) or intermittent cold (cold group, n = 14) retrograde blood cardioplegia. Right-ventricular function was assessed by determining the ejection fraction (fast-response thermodilution) and preload-related RV stroke work in repeated measurements. The RV ejection fraction remained steady in the warm group during the postoperative course, while it declined significantly in the cold group after operation and differed from that in the warm group until the second postoperative day (p < 0.05-0.001). The ratio of RV stroke work to right atrial pressure was greater postoperatively in the warm than in the cold group until 6 hours after cardiopulmonary bypass (p < 0.05-0.01). Creatine kinase cardiac isoenzyme release was greater in the cold group (p < 0.01). The relationship between left-ventricular stroke work and corresponding preload did not differ between the groups. It can be concluded that recovery of RV function after coronary surgery was better in terms of ejection fraction and preload-related stroke work with warm continuous cardioplegia than with intermittent cold cardioplegia, this along with lower cardiac enzyme release suggesting better RV protection.

Analysis of Variance↗
PubMed1977

Comparison of the effect of glucose and fructose on the recovery of the heart preparation.

Reactions of the cardiac muscle of the rat in vitro were investigated in the present study. Cardiac muscle was perfused by Langendorf's method; perfusion pressure was 80 cm H2O and the temperature of the perfusion solution 37 degrees C. The perfusion solution was aerated with a gas mixture of oxygen (95%) and carbon dioxide (5%). Potassium citrate solution was used for heart arrest, and heart function was recovered by infusion of Locke's solution, plus glucose, fructose or sucrose. During recovery the amplitude and frequenty of heart beats, the lactic acid in the drained perfusion solution, pH and potassium concentration were measured. The use of glucose, fructose or sucrose made no significant difference to any of these parameters. Next, the metabolism of glucose and fructose in the heart was investigated by means of D(U-14C)-glucose nad D(U-14C)-fructose. Radioactive lactic acid was detected in the drained perfusion solution with D(U-14C)-glucose, but not when D(U-14C)-fructose was used. The radioactivity incorporated into glycogen by the heart was also larger with D(U-14C)-glucose than with D(U-14C)-fructose. On a metabolic basis the use of glucose for resuscitation would seem to be more appropriate than fructose.

Animals↗
PubMed2006

Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue.

OBJECTIVE: To analyze the results of acute myocardial infarction (AMI) complicated with refractory shock necessitating extracorporeal life support (ECLS) rescue and to search for associated risk factors. DESIGN: Retrospective review of our 9-yr experience with patients initially presenting with AMI with shock necessitating ECLS rescue; analysis of patient outcomes. SETTING: A university-affiliated tertiary referral medical center. PATIENTS: Between 1994 and 2003 inclusively, 36 consecutive patients (age [mean +/- sd], 57 +/- 10 yrs) with AMI complicated by refractory shock and undergoing cardiopulmonary resuscitation (CPR) necessitating emergent ECLS rescue were enrolled in this study. INTERVENTION: All patients underwent CPR before ECLS, although 30 patients (83.3%) received ECLS during CPR because spontaneous circulation failed to return. All patients underwent intraaortic counterpulsation either before or following rescue. Seven patients underwent angioplasty only, and one underwent heart transplantation without any intervention. Twenty-eight patients underwent coronary artery bypass grafting (CABG), in which the beating-heart technique was used for 20 patients. MEASUREMENTS AND MAIN RESULTS: The pre-ECLS blood lactate level was high (13.4 +/- 8.5 mmol/L), as was the inotropic score (121.4 +/- 117.3 microg/kg/min). Twenty-five patients (69.4%) were successfully weaned off ECLS, and 12 (48%) survived to discharge (one had a neurologic deficit). The overall mortality rate was 66.7%. A lower inotropic score, reduced blood lactate level, shorter CPR duration, surgical revascularization, and a reduced total maximal Sepsis-related Organ Failure Assessment (SOFA) score were noted among survivors. Liver failure, central nervous system failure, and renal failure mainly occurred in nonsurvivors after ECLS. The technique used for surgical revascularization (beating heart or arrested heart) did not influence the outcome. ECLS is associated with a lower mortality rate than that expected (>90%) from the resultant total maximal SOFA score (16.6 +/- 3.0). CONCLUSIONS: : AMI complicated with refractory shock remains associated with a high mortality rate, even following ECLS rescue, although ECLS might afford a better chance of survival. The SOFA score can be applied to ECLS condition as a reference point for predicting outcome.

Advanced Cardiac Life Support↗
PubMed1998

Port-Access coronary artery bypass grafting: technical considerations and results.

BACKGROUND: This study reviews the results of an initial experience with minimally invasive coronary bypass surgery using the Port-Access approach in terms of early outcome and safety. METHODS: Between October 1996 and July 1997 49 Port-Access minimally invasive coronary artery bypass grafting procedures were performed at our institution. The patients' mean age was 59.8 years (range 34 to 82 years). Sixteen patients received single vessel and 37 patients received multivessel bypass grafts. RESULTS: There were no operative deaths and no perioperative myocardial infarctions, neurological deficits, or conversions to sternotomy. Early complications included reoperation due to bleeding in 4 patients, reoperation for a pulmonary embolus in 1 patient, and angioplasty for occlusion of a right coronary artery graft in 2 patients. Postoperative angiograms were obtained in 86% (42/49) of the patients and showed 100% patency for left internal mammary artery to left anterior descending artery grafts and 96% patency for all grafts. CONCLUSIONS: These results demonstrate that Port-Access coronary artery bypass grafting using endovascular techniques for cardiopulmonary bypass and cardioplegic arrest can be performed safely with minimal morbidity and mortality. This technique allows multivessel revascularization on a protected, arrested heart with excellent anastomotic precision and reproducible early graft patency. Expanded use of Port-Access techniques is indicated in patients with multivessel coronary artery disease and the technique should be considered for patients with left anterior descending artery restenosis and patients with complex left anterior descending artery lesions where angioplasty results are suboptimal.

Adult↗