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PubMed1987

Intraaortic balloon pump insertion: a randomized study comparing percutaneous and surgical techniques.

To compare the percutaneous and surgical techniques of intraaortic balloon pump insertion, 101 patients referred for this procedure were randomly assigned to either percutaneous or surgical insertion. Insertion using the designated technique was successful in 45 (88%) of 51 patients with percutaneous insertion and 48 (96%) of 50 patients with surgical insertion (difference not statistically significant). The time from the beginning of the insertion procedure to the initiation of counterpulsation was 13 +/- 8 minutes for the percutaneous technique versus 31 +/- 16 minutes for the surgical technique (p less than 0.001). In the percutaneous group, 10 patients required Fogarty thrombectomy after balloon pump removal, and 1 patient developed severe leg ischemia requiring immediate termination of balloon pump support. In the surgical group, one patient developed leg ischemia requiring surgical intervention, three patients developed sepsis with bacteremia (including one patient who required vein patch repair of the femoral artery), one patient developed a wound infection requiring debridement and one patient had a cerebral embolus. Aortic dissection, aortoiliac perforation or amputation did not occur in either group. Major vascular complications occurred in 11 patients (22%) with percutaneous insertion versus 2 patients (4%) with surgical insertion (p less than 0.05). It is concluded that although the percutaneous technique for intraaortic balloon pump insertion is faster than the surgical technique and is technically easy, it is associated with a higher incidence of vascular complications.

Blood Pressure↗
PubMed2000

A novel technique for intraaortic balloon pump placement via the left axillary artery in patients awaiting cardiac transplantation.

In order to circumvent the problems associated with long-term femoral intraaortic balloon pump (IABP) placement we have developed and used a new technique of IABP placement. Over the past three years 13 patients awaiting cardiac transplantation have had placement of IABP via a vein cuff sewn to the left axillary artery. Thirteen patients have undergone IABP placement using this technique. The average duration of IABP support was 37 days (range 10-86 days). Ten patients were successfully transplanted. All patients were allowed to sit, stand and ambulate with assistance. No neurologic complications occurred. There were no episodes of sepsis related to balloon or insertion site. No patient had limb ischemia during IABP counterpulsation. Left axillary artery IABP insertion via a vein cuff portal is a straightforward technique with minimal complications. This method serves as a bridge to cardiac transplantation in a gravely ill group of patients while preserving patient mobility during the waiting period for a donor heart.

Antibiotic Prophylaxis↗
PubMed1998

Coronary artery bypass surgery without cardiopulmonary bypass.

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 +/- 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 +/- 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.

Adult↗
PubMed2001

Catastrophic consequences of a free floating thrombus in ascending aorta.

Floating masses in ascending aorta are an uncommon source of embolism. We report the case of a 46-year-old woman, smoker, on synthetic progestagen, with no previous history of thrombotic events, who was admitted to our emergency department for an acute anterior myocardial infarction. Coronary angiogram showed occlusion of left main coronary trunk. Recanalization of the artery was obtained. Ascending aorta angiogram revealed a free floating mass attached to the aortic wall without evidence of aortic dissection. Transesophageal echocardiography confirmed the presence of a pedunculated mobile mass attached to the aortic wall superior to the left coronary ostium. The patient underwent urgent surgery. Intraoperatively a floating thrombus was localized in the posterior wall of ascending aorta. At macroscopical examination aortic wall and leaflets were normal. Post-operative low cardiac output refractory to inotropic drugs and intraaortic balloon counterpulsation required a circulatory assist device. Consequences for the patient were catastrophic in terms of outcome.

Aorta↗
PubMed2002

Risk factors for intestinal ischaemia in cardiac surgical patients.

OBJECTIVE: Mesenteric ischaemia is an uncommon (<1%) but serious complication of cardiac surgery associated with a mortality >50%. Predictors of this complication are not well defined, and diagnosis can be difficult and prompt surgical intervention can be lifesaving. METHODS AND RESULTS: In a retrospective case-note analysis from May 1994 through to May 2000, we identified mesenteric ischaemia in 39 of 5349 consecutive patients (0.07%) undergoing cardiac surgery with cardiopulmonary bypass. By logistic multivariate analysis, we have identified six possible predictors of intestinal ischaemia: duration of cross-clamp, use of significant inotropic support, intra-aortic balloon counterpulsation for low cardiac output, need for blood transfusions, triple vessel disease and peripheral vascular disease. In all patients a combination of four predictors were present. Patients who survived this complication had surgical intervention earlier (6.4+/-3.8 h) than those who did not (16.9+/-10 h). CONCLUSIONS: The diagnosis and prompt treatment of mesenteric ischaemia post cardiac surgery requires a high degree of awareness. These predictors may be useful in alerting medical staff to the possibility of gastro-intestinal ischaemic complications after cardiac surgery particularly that early surgical intervention reduces mortality.

Cardiac Surgical Procedures↗
PubMed2002

Bridge to transplantation with the DeBakey VAD axial pump: a single center report.

AIMS: To report our experience with a left ventricular assist device axial pump as a bridge to transplantation: the DeBakey Ventricular Assist Device (VAD). METHODS: From February 1999 to February 2002, nine patients (among which eight males), with a mean age of 47 years, all in NYHA functional class IV, were proposed for a bridge to transplantation with the DeBakey VAD. Five patients had primary dilated cardiomyopathy, four had ischemic cardiomyopathy. All the patients had inotropic support prior to the intervention (dobutamine with a mean dose of 12 mcg/kg per min), six had an intra-aortic counterpulsation, four presented ventricular rhythm disorders. Interventions were performed through sternotomy alone (no need for an abdominal pocket) under extra-corporeal circulation on beating heart (except in one patient suffering from an apical thrombosis for which cardioplegic arrest was performed) as followed: implantation of the apical inflow cannula, tunneling of the percutaneous cable, implantation of the outflow graft under aortic side clamping, starting of the DeBakey VAD during CPB weaning-off. RESULTS: Mean support duration was 81+/-62 days (16-224 days). Eight reoperations were required (three for bleeding or cardiac tamponade, one for haemoperitoneum, one for aortic bifurcation thrombectomy, one for right ventricular assist device implantation, two for iterative replacements of the DeBakey VAD). A significant hemolysis was observed in two patients. No device infection or dysfunction were observed. Secondary recovery of a pulsed flow was observed either clinically or by Echo-Doppler in six patients. Five patients were transplanted, four died prior to transplantation (three from multi-organ failure on post-operative day 35, 16 and 50, respectively, and the last patient was found disconnected at day 109). CONCLUSIONS: The DeBakey VAD is at the origin of renewed interest for continuous flow assist devices. Still under evaluation, the advantages of miniaturization and facility of implantation of this new device seem to be promising.

Adult↗
PubMed2003

Postinfarction ventricular septal defect closure with Amplatzer occluders.

OBJECTIVE: Postinfarction ventricular septal defect (PIVSD) is a rare and life-threatening complication with high risk of both surgical and medical treatment. Another option available now is transcatheter closure. The purpose of this paper is to report the results of such treatment with Amplatzer occluders. METHOD: Seven patients aged from 51 to 71 years were included. The procedure was performed between 2 and 10 weeks after myocardial infarction. One patient had double residual VSD (2 months after previous surgery) and another, coexisting critical stenosis of right coronary artery (RCA). All patients were in III/IV NYHA class, on intropes, one patient on aortic balloon counterpulsation. Venous jugular approach was used to close the VSD in six patients, venous transfemoral in one patient. Implantation of six Ampaltzer atrial septal occluders (ASO) and one muscular Amplatzer VSD occluder (VSO) were performed. RESULTS: All procedures but two were finished successfully. In one patient, the defect could not be entered neither from the venous nor the arterial side due to unusual oblique course (which was confirmed during subsequent operation). In the second patient (2 weeks after MI), the reason was unstable position of 24 mm ASO (probably due to necrotic borders of VSD). Immediate significant clinical improvement was achieved in all patients, in whom PIVSD was closed with Amplatzer occluders. In one postsurgical patient, two ASO were used; in another patient, prior to VSD closure, PTCA and stent implantation to RCA was performed. The stretched diameter of PIVSD ranged from 8 to 22 mm, the size of implanted Amplatzer occluders from 12 to 24 mm. Fluoroscopy time was 60 min (18-120). During the procedure, ventricular fibrillation requiring defibrillation was observed in three patients. One patient died 1 week after the procedure because of multiorgan failure and increasing mitral incompetence (MI). CONCLUSIONS: Despite some technical problems, implantation of Amplatzer occluders, is an attractive option of treatment of patients with subacute PIVSD.

Aged↗
PubMed2003

Multivessel off-pump revascularization in patients with severe left ventricular dysfunction.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of multivessel beating heart revascularization in a high-risk group of patients with severe left ventricular dysfunction as well as to provide intermediate survival and quality of life data. METHODS: Our prospectively updated database was queried to extract all patients with left ventricular ejection fraction < or =30% who underwent beating heart revascularization. Standard demographics, clinical profiles and outcomes were collected. Outcomes were compared with Society of Thoracic Surgeons (STS) benchmarks for all coronary artery bypass grafting (CABG) patients. Telephone interviews were conducted and survival and quality of life data were tabulated. In addition, morbidity and mortality outcomes were compared with a concurrent cohort of patients with similarly impaired left ventricular function who underwent conventional coronary artery bypass. RESULTS: One hundred off-pump coronary artery bypass grafting patients were identified and follow-up was 93% complete in these patients. Mean age was 67+/-10.5 years and mean ejection fraction was 26+/-4%. Twenty-one percent were females. Balloon counterpulsation support was used liberally in the perioperative period. Patients received a mean of 3.5 grafts with 83% internal mammary artery use. Observed mortality was 3% with a predicted mortality of 5.3%. Observed to expected ratio was 0.56. Incidence of adverse events compared favorably with both that reported in the STS for all CABG patients regardless of left ventricular function, and also to a concurrent CABG cohort. One-year survival was 85%. Freedom from cardiac readmission was 88% and freedom from angina was 83%. No patient required repeat percutaneous or surgical intervention. CONCLUSIONS: We conclude that multivessel off-pump revascularization in patients with severe left ventricular dysfunction is a safe and effective alternative to conventional grafting. Long-term follow-up is mandatory to confirm these encouraging intermediate outcomes.

Aged↗
PubMed2003

Comprehensive experience with the Ross operation in Spain.

OBJECTIVE: Although the first pulmonary autograft operations were performed in Spain in 1991, this procedure has gained substantial interest and has been consolidated since 1997. The establishment of the Spanish Registry of the Ross Operation pretends to evaluate the results of this option in aortic valve disease patients in our setting. METHODS: In a yearly fashion, the cardiac surgery departments in Spain currently performing this intervention send data from new patients or follow-ups to the reference center. Preoperative, intraoperative and postoperative data are included in the registry, with special attention to morbidity, mortality, autograft and homograft dysfunction and need for reintervention. RESULTS: Since February 1991 to May 2002, 169 patients have been treated with this technique. The most prevalent aortic disease was regurgitation (72; 42.59%), congenital being the most frequent etiology (108; 63.9%). Four (2.36%) patients required intraoperative aortic counterpulsation. Operative mortality was 2.36% (n=4). Follow-up is 98.7% complete, with an average of 36.08+/-31.09 months (range 1-135), 84 patients (49.7%) were followed for more than 2 years. The autograft remains competent or with trivial to mild regurgitation in 161 patients (95.6%), presenting two (1.18%) with severe regurgitation. The homograft was normal or with mild stenosis in 159 patients (94.07%), presenting five (2.95%) with severe stenosis. Three (1.77%) required reintervention (surgical or interventional) on the right ventricular outflow tract and four (2.36%) required autograft replacement for a mechanical prosthesis. Actuarial survival is 95.99+/-1.65% at 36 months, remaining 92.44+/-2.55% free from reintervention in the same period. CONCLUSIONS: The Ross operation is an increasingly popular surgical option in Spain, and although the number of patients and length of follow-up are still limited, initial results are at least as good as those reported internationally. It is important to continue a close follow-up of these patients to assess the long-term function of auto and homograft. With the available data, we believe that this therapeutic approach is a valid option for selected groups of patients with surgical aortic valve disease in Spain.

Adolescent↗
PubMed1995

The Edinburgh Cardiac Surgery Score survival prediction in the long-stay ICU cardiac surgical patient.

Predictors of outcome in long-stay patients following cardiac surgery have hitherto been ill defined. The aims of this study were to test the Parsonnet pre-operative scoring system and to define a scoring system for inhospital mortality applicable post-operatively to strengthen the clinical decision-making process. Following case note review of 262 consecutive patients who stayed 7 days or more in intensive care, a total of 110 pre-, intra- and post-operative factors were documented. In this long-stay group the Parsonnet score was confirmed to be predictive of 30 day mortality. Univariate analysis identified significant association between mortality in the Intensive Care Unit (ICU) and the following: inotrope days, (defined as number of inotropes times number of days) ventilation, units of platelets (P = < 0.00001), chest reopening, fresh frozen plasma units (P < 0.002), total parenteral nutrition, noradrenaline, Parsonnet score (P = 0.005), dopamine, bypass time, vasodilators, intra-aortic balloon counterpulsation, enteral nutrition and other major surgery (P < 0.05). Stepwise logistic regression on these significant factors was used to produce the Edinburgh Cardiac Surgery Score (ECS) applicable from Day 10 onwards in the intensive care unit: ECS Score = (Inotrope days) +2 (Ventilation) + (Platelets) + (Parsonnet) -3. The ECS score may be a useful predictor of ICU mortality probability for cardiac surgical patients requiring 10 days or more intensive care and is presently undergoing prospective evaluation in our centre.

Adult↗
PubMed1997

Single aortic cross-clamp technique in coronary surgery: a prospective randomized study.

OBJECTIVE: To test the hypothesis of an improved myocardial and cerebral protection by combining blood cardioplegia and the single aortic cross-clamp technique, 100 patients were enrolled in a prospectively randomized study and stratified for preoperative conditions. METHODS: In Group I, 55 patients underwent myocardial revascularization using crystalloid cardioplegia and the conventional partial occluding clamp technique to perform proximal anastomoses, whereas in Group II, 45 patients were operated on combining blood cardioplegia and the single aortic cross-clamp technique. Unstable angina, emergency procedures, reoperations and preoperative counterpulsation accounted for an higher risk score in group II patients (P < 0.03). Operations were performed by the same surgical team. Aortic cross-clamp time was significantly longer in group II patients (59 +/- 22 vs. 47 +/- 18 min.) (P < 0.001). Other intraoperative variables were not significant. RESULTS: A 70-year-old male in group I died on post-operative day 5 as a consequence of a major neurological event. Length of ventilatory dependency, post-operative bleeding, need for blood transfusions, ICU stay, and hospital stay were similar between the two groups (P = NS). Patients in group I showed a strict correlation between the duration of surgical ischemia and post-operative myocardial necrosis. Analysis of combined mortality and morbidity events (adverse events) between the two groups, led to a significant prevalence in group I patients (P < 0.03) in spite of an higher pre-operative risk score and longer ischemic times in group II patients. Neurological lesions remained confined to group I patients. CONCLUSIONS: The combined use of blood cardioplegia, delivered via the antegrade and retrograde routes, and the single-clamp technique to perform myocardial revascularization, might enhance myocardial and cerebral protection when compared to conventional methods. Larger groups of patients are needed to support this trend.

Adult↗
PubMed1998

Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure.

OBJECTIVE: Partial left ventriculectomy (PLV), pioneered by Batista, has been proposed as an alternative treatment strategy in patients with refractory congestive heart failure. In order to analyze the midterm outcome of PLV and mitral valve (MV) repair and stratify patients according to risk, we prospectively studied 57 consecutive patients who underwent this procedure at the Cleveland Clinic Foundation (CCF). METHODS: Patients had a mean age of 53 years and were predominantly males (74%). In 95% the etiology of heart failure was idiopathic dilated cardiomyopathy. All patients had a left ventricular end diastolic diameter of >7cm and were in New York Heart Association (NYHA) functional classes III and IV. A total of 54 patients (95%) were awaiting heart transplantation. Preoperatively, requirements included inotropes in 23 (40%), intraaortic balloon pump counterpulsation in 3 (5.3%), and left ventricular assist device placement (LVAD) in 1 (1.8%). Concomitant procedures included MV repair (55 patients), MV replacement (2), tricuspid valve repair (34 patients), coronary artery bypass graft (CABG) (5), and aortic valve repair or replacement (1 patient each). RESULTS: Measurements preoperatively and at 3 months demonstrated improvement in left ventricular ejection fraction (14.4 +/- 7.7-23.2 +/- 10.7%, P < 0.001), left ventricular end diastolic volume (254 +/- 85-179 +/- 73 ml, P < 0.001) and left ventricular end diastolic diameter (8.4 +/- 1.1-6.3 +/- 0.9 cm, P < 0.001). Peak oxygen consumption (MVO2) increased from 10.6 +/- 3.9 to 15.3 +/- 4.5 ml/kg per min (P < 0.001). Cardiac index did not change (2.2 l/min per m2), although 40% had been on inotropes preoperatively and none were on inotropes at 3 months. NYHA functional class improved from 3.6 +/- 0.5 preoperatively to 2.2 +/- 0.9 at 3 months (P < 0.001). LVAD support was required as rescue therapy in 11 patients (17%). Actuarial freedom from procedure failure, defined as death or relisting for transplant, was 58% at 1 year. Hospital mortality was 3.5% (n = 2). On follow-up, there were 7 late deaths (including 3 sudden deaths) giving an actuarial survival of 82% at 1 year. Multivariate risk factor analysis revealed that age less than 40 years was associated with failure (P = 0.02). CONCLUSIONS: Although PLV with MV repair is now a surgical option in the treatment of end-stage congestive heart failure, caution is advised as early failures are unpredictable and mechanical support may be required as rescue therapy. Better risk stratification and patient selection may improve outcome. Further study is required to determine the procedure's exact role in the treatment of congestive heart failure.

Adolescent↗
PubMed1998

Coronary artery bypass grafting without cardiopulmonary bypass--initial experience of 50 cases.

This study was undertaken to assess our experience with the first 50 patients who underwent CABG without cardiopulmonary bypass. In seven patients left internal mammary artery to left anterior descending artery (LIMA-LAD) grafting was performed through a short left anterior thoracotomy. In 43 other patients median sternotomy was used. Primary CABG was performed in 48 patients; there were two reoperations. Eleven patients had unstable angina. Three patients had left ventricular ejection fraction (LVEF) equal to or lower than 25%. One patient had carcinoma of the right lung coexisting with unstable angina and underwent also right lower lobectomy. In each patient the clinical course, 12-lead ECG, transthoracic echocardiography and the serum levels of creatine kinase (CPK), alanine aminotransferase (ALAT), aspartate aminotransferase (AspAT) were assessed. The need for inotropic or intraaortic balloon counterpulsation (IABP) support and blood transfusion was also recorded. There were three deaths, all in the sternotomy group (6%). A patient with systemic lupus erythemetodes (SLE) died of postoperative MI due to graft thrombosis. Another patient who was found to have porcelain aorta and had LIMA-LAD grafting as a rescue procedure died of MI with low cardiac output. The third patient with unstable angina and ejection fraction of 30% developed postoperative MI with ventricular arrhythmia. One patient with LIMA-LAD graft in whom percutaneous translaminal coronary angioplasty (PTCA) had been abandoned because of coronary spasm developed acute myocardial ischaemia 5 h postoperatively. He had a vein graft placed to LAD in cardiopulmonary bypass, his further course was uneventful. Six patients had IABP support. Nine patients needed inotropic support. Ten patients received blood transfusion. Twelve-lead ECG did not show acute ischaemia or MI, apart from the above described cases. Echocardiographic check showed improved IVS contractility in three patients and better apex motion in one case. In the other survivors the echocardiographic findings were the same as before the procedure. ALAT and AspAT serum levels were normal in all the survivors, and the CPK levels did not exceed 200 IU/ml. One patient from the mini-thoracotomy group had recurrent angina 2 months after the procedure. His left internal mammary artery (LIMA) graft was occluded; we replaced it with a vein graft. All 47 survivors remain asymptomatic, with the mean follow-up time of 6 months. Coronary surgery without cardiopulmonary bypass seems a valuable alternative for high-risk patients.

Cardiopulmonary Bypass↗
PubMed1999

Surgical treatment of left ventricular post-infarction aneurysm with endoventriculoplasty: late clinical and functional results.

OBJECTIVE: The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique. METHODS: From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software. RESULTS: The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum). CONCLUSIONS: We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Adult↗
PubMed1999

Non-cardioplegic coronary surgery in patients with severe left ventricular dysfunction.

OBJECTIVES: Although most surgeons use cardioplegia for myocardial protection during coronary artery bypass grafting (CABG), some still use non-cardioplegic methods with very good early and long-term outcome. However, the results in patients with severe left ventricular dysfunction remain unproved. This study evaluates the perioperative mortality and morbidity in patients with severe left ventricular dysfunction submitted to CABG using non-cardioplegic methods. METHODS: From April 1990 through December 1997, 3,180 patients were consecutively subjected to isolated CABG using non-cardioplegic methods, for construction of the distal anastomoses. This prospective study is based on the 107 (3.4%) patients with severe impairment of the left ventricular function (ejection fraction < 30%). The mean age at operation was 57.0 +/- 9.2 years and 95.3% of patients were male. Fifty three patients (49.5%) were in class CCS III/IV and 12 (11.2%) were subjected to urgent surgery. A history of previous myocardial infarction was recorded in 99 (92.5%) patients. Ninety seven (90.6%) patients had triple vessel and 17 (15.9%) left main stem disease, and 77 (71.9%) had a left ventricular end-diastolic pressure > 20 mmHg. Cardiopulmonary bypass time was 73.1 +/- 21.7 min. The mean number of grafts per patient was 3.2. At least one internal mammary artery was used in all cases and 16 patients (14.9%) had bilateral internal mammary artery grafts (1.2 arterial grafts/patient). Endarterectomies were performed in 23 (21.5%) patients. RESULTS: Perioperative mortality was 2.8% (respiratory-1; cardiac-2). Forty one (38.3%) patients required inotropes, but for longer than 24 h in only 12 (11.2%), and two (1.9%) needed intra-aortic counterpulsation. The incidence of myocardial infarction was 2.8%. Two (1.9%) patients had reintervention for haemorrhage and another five (4.6%) for sternal complications. The incidences of supraventricular arrhythmias, renal failure and cerebrovascular accident were 16.8%, 3.6% and 2.8%, respectively. The mean time of hospital stay was 9.3 +/- 6.4 days. CONCLUSION: These results appear to demonstrate that non-cardioplegic methods afford good myocardial protection and operating conditions with excellent applicability, even in patients with severe left ventricular dysfunction.

Aged↗
PubMed1995

A comparison of prostacyclin and sodium nitroprusside for the treatment of heart failure after cardiac surgery.

OBJECTIVE: To study the effects of the two vasodilators, prostacyclin and sodium nitroprusside, on central hemodynamics in heart failure after cardiac surgery. DESIGN: Randomized cross-over study. SETTING: Multi-institutional university hospital. PARTICIPANTS: Ten patients. INCLUSION CRITERIA: cardiac index less than 2.5 L/min/m2; pulmonary capillary wedge pressure greater than 15 mmHg, systemic vascular resistance index greater than 2,500 dynes.s.cm-5/m2, and treatment with inotropic support. Five patients were treated with intra-aortic balloon counterpulsation. INTERVENTIONS: After control measurements, mean arterial pressure was decreased by 10% to 20% with each vasodilator in each patient. MEASUREMENTS AND RESULTS: Sodium nitroprusside induced decreases in mean pulmonary arterial pressure (-21%), pulmonary capillary wedge pressure (-29%), central venous pressure (-17%), and systemic vascular resistance (-25%), and increases in cardiac output (+7%) and stroke volume (+6%) compared with control. Prostacyclin decreased mean pulmonary arterial pressure (-14%), pulmonary capillary wedge pressure (-19%), central venous pressure (-7%), and systemic (-40%) and pulmonary (-25%) vascular resistances, whereas cardiac output (+25%) and stroke volume (+22%) increased compared with control. Prostacyclin, compared with sodium nitroprusside, induced a more pronounced increase in cardiac output and stroke volume, associated with less pronounced decreases in cardiac filling pressures and more profound decreases in systemic and pulmonary vascular resistances. CONCLUSION: Prostacyclin appears to be a useful agent, superior to sodium nitroprusside, in the treatment of postoperative heart failure in patients with normal or mildly elevated cardiac filling pressures, where vasodilator treatment is indicated.

Aged↗
PubMed1999

Intravenous thyroid hormone supplementation in heart failure with cardiogenic shock.

BACKGROUND: Thyroid hormone level abnormalities commonly exist in severe heart failure and may be of prognostic value. The therapeutic potential of using thyroid hormone for cardiogenic shock resulting from progressive heart failure has not been previously delineated. We sought to evaluate the role of an intravenous infusion of thyroxine as an adjunct to conventional inotropic agents and intra-aortic balloon counterpulsation in patients with severe heart failure with cardiogenic shock. METHODS AND RESULTS: We studied 10 consecutive patients with severe systolic heart failure that progressed to a cardiogenic shock state unresponsive to conventional pharmacological inotropic measures. Intravenous thyroxine (20 micrograms/h) was used as an adjunctive salvage measure after the failure of conventional pharmacological and mechanical support by intra-aortic balloon pump. The invasive hemodynamic profile (right atrial pressure, pulmonary capillary wedge pressure, cardiac index, mean arterial pressure), overall clinical status, core temperature, renal function, and tachyarrhythmias were compared before and sequentially at 6, 24, and 36 hours after the initiation of thyroxine administration. Long-term outcome was also defined. All patients had statistically significant improvements in cardiac index, pulmonary capillary wedge pressure, and mean arterial pressure at 24 and 36 hours post-initiation of thyroxine. No sustained tachyarrhythmias were seen during the thyroxine infusion. In 9 of 10 patients who underwent left ventricular assist device placement and/or heart transplantation, the use of thyroxine served as an effective adjunctive measure to allow transitioning to definitive surgical therapy. The 6-month and 1-year cohort survival rates, achieved by the transition to surgical therapy, were 90% and 80%, respectively. CONCLUSION: The beneficial hemodynamic properties of intravenous thyroid hormone can be effectively used in otherwise terminal situations of cardiogenic shock, and in such situations, the use of thyroid hormone can serve as a pharmacological adjunct to a definite surgical intervention. Further studies in larger numbers of patients might be warranted to confirm these findings.

Adult↗
PubMed2003

Effect of early revascularisation in cardiogenic shock complicating acute myocardial infarction. A single center experience.

BACKGROUND: Five to 10% of patients with acute myocardial infarction develop cardiogenic shock and the majority of these patients are expected to die within the first few weeks. In this study, we review our recent experience in the management of patients with cardiogenic shock complicating MI and examine the effect of early invasive revascularisation on mortality. METHODS: Thirty-six consecutive patients who developed cardiogenic shock less than 48 h after MI were retrospectively evaluated and divided into two treatment groups. One group received early invasive revascularisation (n=24) and the other group had no early invasive revascularisation, but received similar conventional intensive care medical treatment (n=12). RESULTS: Baseline characteristics and hemodynamic variables were similar in both groups. Apart from invasive revascularisation and the use of intra aortic balloon counterpulsation (IABP), treatment strategies did not differ between the two groups. Thirty-day mortality was 21% in the revascularised group of patients and 58% in the non-revascularised group (P<0.05). CONCLUSIONS: Our data support previous observations suggesting that an aggressive treatment strategy including early invasive revascularisation and IABP is associated with improved short and long-term survival in patients with cardiogenic shock. Since early revascularisation appears safe with a considerable treatment benefit, this approach must be considered in patients with short shock duration early after MI.

Abciximab↗