Coronary bypass with arterial conduits

To assess the efficacy of arterial revascularization 368 patients were studied who underwent myocardial revascularization with two or more arterial conduits (group M) and compared with 2092 patients in whom a single internal mammary artery±veins (group S), and to a third group in which only saphenous vein conduits (group V, n=602) were used. Group M patients were younger (aged 54.0(9.5) years; 4.1% aged >70 years) than either group V (67.6(8.9) years, 40.7% >70 years, P<0.0001) or group S patients (62.0(8.5) years, 15.7% >70 years, P<0.0001). Furthermore, this cohort group had the lowest percentage of females (8.4%), of urgent cases (21.7%), of preoperative myocardial infarction (6.0%), and of redo surgery (0.8%). In contrast, patients who received only saphenous vein conduits had the highest proportion of female patients (29.2%), of urgent cases (47.4%), of preoperative myocardial infarction (16.5%), and of redo surgery (5.5%). By multivariate logistic regression analysis (odds ratio in parentheses), redo surgery (6.06, P=0.0001), preoperative intra-aortic balloon pump assist (6.11, P=0.0001), diabetes (1.97, P=0.03), urgent surgery (1.80, P=0.05), and advanced age (2.14, P=0.01) were all predictors of operative mortality. In contrast, while choice of conduit appeared to influence outcome by univariate analysis (4.2% mortality in group V, P<0.001), it was not found to be a predictor of either mortality or morbidity by regression analysis. The present results indicate that, in carefully selected patients, despite increased technical demands with longer periods of aortic occlusion and longer pump times, multi-arterial grafting (compared with conventional revascularization) is a safe and efficacious procedure. Whether or not this approach to revascularization will increase long-term survival and freedom from reoperation will require further study.     

The radial artery in reoperative coronary bypass surgery:

BACKGROUND: Failure of saphenous vein grafts (SVG) is a significant cause for coronary reoperation (redo CABG). The radial artery (RA) because of its availability, and versatility is well suited to use (together with internal thoracic arteries (ITA) in redo CABG, especially to replace failed SVG. We evaluated our experience where the RA was a major conduit in redo CABG over the past 5 years. METHODS: From July 1996 to June 2002, 590 consecutive patients underwent redo CABG where one or both RA(s) were used, together with LITA or RITA. The mean age was 67.3 years, 82% were male, and 19% diabetic, 419 (71%) had Class III or IV angina, 135 (23%) had left main stenosis, and 210 (36%) had an LVEF < 0.50. There were a total of 877 RA conduits (303 single, 287 bilateral), 518 new LITA or RITA. A mean of 2.8 new distal anastomoses constructed 92% (2.6 per patient)of the arterial grafts. Follow-up was at 1 month, 3 months, and then yearly. The results were compared with 6466 primary CABG performed in the same time frame, and with a prior cohort of 741 consecutive patients having redo CABG without an RA in which identical operative techniques had otherwise been used. RESULTS: The 30-day mortality was 3.9% (23 patients). Morbidity was low. Perioperative myocardial infarction occurred in 16 (2.7%) patients, stroke in 10 (1.7%), sternal infection in 10 (1.7%), donor site infection in 2 (0.3%), and IABP use in 23 patients (3.9%)-including 10 preoperatively. The results were better when compared to a prior cohort of 741 patients with redo CABG (1991 to 1996) without use of the RA. The results were inferior to that of the contemporary primary CABG. Operative mortality was 3.9% versus 0.9%, p = 0.002, myocardial infarction 2.7% versus 0.8%, p = 0.03. CONCLUSION: The use of the RA (together with ITA) in redo CABG achieved total arterial revascularization in 92% of cases and is associated with excellent results, at least equal to or superior to those achieved previously.     

Does Coronary Endarterectomy Adversely Affect the Results of Bypass Surgery?

Coronary endarterectomy (TEA) is performed infrequently during coronary artery bypass graft (CABG) surgery due to the impression that it results in higher rates of myocardial infarction (MI), operative mortality (OM), and poor long-term outcome. To assess the effectiveness of TEA, 1, 228 patients undergoing isolated CABG between 1982 and 1989 were evaluated. The incidence of OM (3.2%) and MI (6.0%) following TEA was similar to conventional CABG (OM = 3.8%, MI = 5.5%, p = NS). The incidence of low output syndrome (LOS, 15.1%) and intraaortic balloon pump insertion (IABP, 4.5%) following TEA was similar to conventional CABG (LOS = 12.6%, IABP = 6.0%, p = NS). The highest level of the cardiac specific isoenzyme (CK-MB) released following surgery was similar for the TEA group (46 ± 49) and conventional CABG group (42 ± 44, p = NS). Ventricular dysfunction, urgent surgery, left main stenosis, advanced age, and reoperative surgery were similar in the TEA and conventional CABG groups. At a mean follow-up of 4.2 years, 65.6% of all TEA patients were free of angina, 44.4% were gainfully employed, and 62% were in New York Heart Association Class I. The incidence of late myocardial infarction was 5.4%. The 5-year actuarial survival was 90%. Patients with double TEA and limited TEA (< 3 cm TEA specimens) tended to have a lower 5-year survival. With strict criteria for selection of TEA patients and with significant technical experience, the short- and long-term results of TEA are comparable to conventional CABG.     

Short‐ and long‐term outcomes following redo valvular surgery

Aim

We reviewed our experience in redo valvular surgery to evaluate trends in short‐ and long‐term outcomes.

Methods

We reviewed 414 patients (mean age, 62.8 ± 13.6 years) who underwent redo valvular surgery in the past 25 years. A total of 301 patients (54.2%) underwent first‐time redo valvular surgeries; 178 (32.1%) were second redos, 60 (10.8%) were third redos, and 16 were fourth redos (2.9%). The mean follow‐up period was 6.8 ± 6.3 years.

Results

Hospital mortality was 5.8%. New York Heart Association (NYHA) class III/IV (P = 0.0007, odds ratio = 4.403) and hemodialysis (P = 0.0383, odds ratio = 7.196) were risk factors for hospital death. Long‐term survival rates at 15 and 20 years were 64.7% ± 4.3% and 59.1% ± 5.0%, respectively. Predictors of late death were first time redo (P = 0.0076, hazard ratio = 0.422) and age younger than 61 years (P = 0.0005, hazard ratio = 0.229). There were significant differences in long‐term survival between NYHA classes I/II and III/IV (log‐rank test, P = 0.0419) and between the time from redo surgery (log‐rank test, P = 0.0189) and age (log‐rank test, P = 0.0001).

Conclusions

The hospital mortality rate for redo valve surgery has improved. Early referral for redo surgery can contribute to improving early and late outcomes.     

Beneficial Effect of Preventative Intra-Aortic Balloon Pumping in High-Risk Patients Undergoing First-Time Coronary Artery Bypass Grafting—A Single Center Experience

Although intra‐aortic balloon pumping (IABP) has been used widely as a routine cardiac assist device for perioperative support in coronary artery bypass grafting (CABG), the optimal timing for high‐risk patients undergoing first‐time CABG using IABP is unknown. The purpose of this investigation is to compare preoperative and preventative IABP insertion with intraoperative or postoperative obligatory IABP insertion in high‐risk patients undergoing first‐time CABG. We reviewed our IABP patients' database from 2002 to 2007; there were 311 CABG patients who received IABP treatment perioperatively. Of 311 cases, 41 high‐risk patients who had first‐time on‐pump or off‐pump CABG (presenting with three or more of the following criteria: left ventricular ejection fraction less than 0.45, unstable angina, CABG combined with aneurysmectomy, or left main stenosis greater than 70%) entered the study. We compared perioperatively the clinical results of 20 patients who underwent preoperative IABP placement (Group 1) with 21 patients who had obligatory IABP placement intraoperatively or postoperatively during CABG (Group 2). There were no differences in preoperative risk factors, except left ventricular aneurysm resection, between the two groups. There were no differences in indications for high‐risk patients between the two groups. The mean number of grafts was similar. There were no significant differences in the need for inotropes, or in cerebrovascular, gastrointestinal, renal, and infective complications postoperatively. There were no IABP‐related complications in either group. Major adverse cardiac event (severe hypotension and/or shock, myocardial infarction, and severe hemodynamic instability) was higher in Group 2 (14 [66.4%] vs. 1 [5%], P < 0.0001) during surgery. The time of IABP pumping in Group 1 was shorter than in Group 2 (72.5 ± 28.9 h vs. 97.5 ± 47.7 h, P < 0.05). The duration of ventilation and intensive care unit stay in Group 1 was significantly shorter than in Group 2, respectively (22.0 ± 1.6 h vs. 39.6 ± 2.1 h, P < 0.01 and 58.0 ± 1.5 h vs. 98.5 ± 1.9 h, P < 0.005). There were no differences in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2). Preoperative and preventative insertion of IABP can be performed safely in selected high‐risk patients undergoing CABG, with results comparable to those in patients who received obligatory IABP intraoperatively and postoperatively. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome in high‐risk first‐time CABG patients.     

Based on acute outcomes, "all arterial" coronary bypass surgery should be performed on younger elective patients.

OBJECTIVES: This study evaluated acute results as a function of the number of arterial conduits used to compare procedural differences and the subsequent effects on acute outcomes in selected patient populations. BACKGROUND: All arterial operations may provide better long-term results for younger patients undergoing coronary bypass surgery (CABG). However, concerns regarding additional morbidity when using multiple arterial conduits have inhibited their use. METHODS: The study comprised a retrospective review of patients (2,586) undergoing CABG. Group 1 consists of single artery vein graft (1,755). Group 2: two arteries were used in addition to vein grafts (209). Group 3: three or more arterial conduits were used, with or without vein grafts (116). Group 4: only vein grafts were used (506). RESULTS: Patients undergoing primarily arterial procedures, Group 2 and 3, were younger, had a better exercise profile, less history of myocardial infarction (MI), had less left ventricular dysfunction. There were also fewer emergencies, co-morbidities and associated procedures in this group. The cardiopulmonary bypass and cross clamp times were longer in those procedures with three or more arteries; however, this difference was only thirteen and fourteen minutes, respectively. Post-operative complications were higher in patients in the vein only group. The hospital stay and mortality was equivalent among groups in which an arterial bypass was used and better than those in which only vein grafts were used. CONCLUSIONS: For younger patients, "all arterial operations," require only minimal increases in ischemic and operative times, which do not affect acute outcomes.     

The use of preoperative intra-aortic balloon pump in open heart surgery

AIM: Intra-aortic balloon pump (IABP) therapy before open heart surgery has been suggested for 'high risk' patients. METHODS: Records from patients undergoing open heart surgery at our institution between June 1999 and February 2002 were reviewed. Indication for IABP insertion was severely impaired left ventricular function, acute myocardial infarction (MI) or unstable angina. RESULTS: Fifty-five patients were included in the study: 41 male, 14 female, age 64+/-9 years. Fifty-one (92.7%) required coronary artery bypass brafting (CABG) alone or as a combined procedure, 2 (3.6%) required mitral valve surgery, and 2 (3.6%) needed more complex cardiac procedures. Thirty-two patients (58%) underwent emergency cardiac surgery and 11 patients (20%) suffered from acute preoperative MI. The overall 30 days mortality was 9%. Mean intensive care unit (ICU) stay was 6+/-8 days. Four patients (7.2%) developed postoperative renal failure requiring temporary hemodialysis. Three patients (5.4%) developed IABP related peripheral vascular complications. CONCLUSIONS: Perioperative morbidity and mortality is increased despite preoperative IABP, particularly in patients with acute MI. In contrast to studies not using this approach, preoperative IABP reduces morbidity and mortality of high risk patients. IABP related complications are low. Our data suggest that high risk patients profit from preoperative IABP therapy, however, prospective studies are needed to confirm these findings.     

Timely use of a CentriMag heart assist device improves survival in postcardiotomy cardiogenic shock

Abstract Background: Postcardiotomy cardiogenic shock (PCS) is often fatal despite inotropic and circulatory support. We compared our experience with the CentriMag left ventricular assist device (LVAD) for patients with PCS at two time periods: in the operating room (OR) after unsuccessful weaning from cardiopulmonary bypass (CPB) and after transfer to the intensive care unit (ICU). Methods: We reviewed 22 patients’ records (13 men, nine women; age, 65 ± 12 years) who underwent open heart surgery (January 2004 to September 2009) and required LVAD support for PCS despite maximal inotropic and intra‐aortic balloon pump (IABP) support. In ten patients who could not be weaned from CPB despite high‐dose inotropic therapy (≥ 3 agents) and IABP support, the CentriMag was implanted in the OR (immediate group). The other 12 patients were weaned from CPB with high‐dose inotropic therapy and IABP but became increasingly unstable or had a cardiac arrest in the ICU, and the CentriMag was implanted for circulatory support (delayed group). Results: Preoperatively, the average ejection fraction was 40%± 12%, the creatinine level was 1.6 ± 0.6 mg/dL, and the European Systematic Coronary Risk Evaluation was 13.1 ± 4.6. The duration of CentriMag support was 5 ± 3 days. The immediate group had significantly better survival (7/10 vs. 2/12, p = 0.027), higher cardiac index (2.4 ± 0.3 L/min/m² vs. 1.7 ± 0.3 L/min/m², p = 0.001), and lower pulmonary capillary wedge pressure (20 ± 6 mmHg vs. 29 ± 8 mmHg, p = 0.024) than the ICU group. No perioperative complications related to device implantation occurred. Conclusion: In patients with PCS, timely placement of a CentriMag LVAD may increase the chance of eventual recovery. (J Card Surg 2011;26:548‐552)     

Does the Trainee's Level of Experience Impact on Patient Safety and Clinical Outcomes in Coronary Artery Bypass Surgery?

BACKGROUND: There is a relative dearth of information on how the resident's level of training affects patient outcomes in cardiac surgery. We designed this study to determine if there were any significant differences in patient demographics and clinical outcomes of coronary artery bypass procedures (CABG) performed by residents of PGY 4/lower, residents of PGY 5/6, fellows, or consultants. METHODS: Standardized preoperative, intraoperative, and postoperative variables were prospectively collected and analyzed on 2906 isolated CABG procedures, performed between July 1999 and March 2006 with the primary surgeon prospectively classified as PGY4/lower, PGY5/6, fellow, and consultant. RESULTS: The number of cases performed by residents of PGY4/lower, PGY5/6, fellows and consultants were 179, 263, 301, and 2163, respectively. Preoperative demographics and comorbidities were similar except PGY4/lower group had more diabetics and consultant group had more patients requiring IABP. More non-LIMA arterial conduits were used in the consultant and fellow groups. However, there were neither significant differences in the mean number of grafts nor in the composite postoperative morbidity, median ICU, and hospital lengths of stay. Observed in-hospital mortality was 2.2%, 1.5%, 1.7%, and 2.7% (p = 0.49), respectively. CONCLUSIONS: Preoperative patient demographics and operative data were similar in all groups except that patients requiring IABP preoperatively were more likely operated on by consultants and arterial revascularization was performed more commonly by consultants and fellows. Postoperative mortality and morbidity rates were similar among all groups, thus demonstrating that with appropriate supervision, trainees of all levels can safely be taught CABG.     

Surgical Reintervention After Failed Antireflux Surgery: A Systematic Review of the Literature

Background  Outcome and morbidity of redo antireflux surgery are suggested to be less satisfactory than those of primary surgery. Studies reporting on redo surgery, however, are usually much smaller than those of primary surgery. The aim of this study was to summarize the currently available literature on redo antireflux surgery. Material and Methods  A structured literature search was performed in the electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Results  A total of 81 studies met the inclusion criteria. The study design was prospective in 29, retrospective in 15, and not reported in 37 studies. In these studies, 4,584 reoperations in 4,509 patients are reported. Recurrent reflux and dysphagia were the most frequent indications; intraoperative complications occurred in 21.4% and postoperative complications in 15.6%, with an overall mortality rate of 0.9%. The conversion rate in laparoscopic surgery was 8.7%. Mean(±SEM) duration of surgery was 177.4 ± 10.3 min and mean hospital stay was 5.5 ± 0.5 days. Symptomatic outcome was successful in 81.1% and was equal in the laparoscopic and conventional approach. Objective outcome was obtained in 24 studies (29.6%) and success was reported in 78.3%, with a slightly higher success rate in case of laparoscopy than with open surgery (85.8% vs. 78.0%). Conclusion  This systematic review on redo antireflux surgery has confirmed that morbidity and mortality after redo surgery is higher than after primary surgery and symptomatic and objective outcome are less satisfactory. Data on objective results were scarce and consistency with regard to reporting outcome is necessary.     

Mild or Moderate Chronic Obstructive Pulmonary Disease Risk in Elective Coronary Artery Bypass Grafting Surgery

A history of chronic obstructive pulmonary disease (COPD) is considered a risk factor in patients undergoing coronary artery bypass grafting (CABG) surgery. The objective of this study was to examine the impact of history of mild or moderate COPD on outcome in patients undergoing elective CABG surgery. In this prospective, case-controlled study, we compared two groups of adult patients undergoing elective CABG surgery. In this prospective, case-controlled study, we compared two groups of adult patients undergoing elective CABG surgery. There were no statistically significant differences regarding early postoperative complications between the groups (p > 0.05). The median duration of mechanical ventilation and ICU length of stay were 0.4 and 1 days, respectively, in the two groups. The mean (± SD) hospital stay was 7.8 ± 1.6 days in the COPD group and 7.5 ± 1.3 days in the control group (p = 0.1). The mortality rate was found 1.4% in COPD patients and 0.7% in the control group (p = 0.5). We concluded that patients with a history of mild or moderate COPD undergoing elective CABG had morbidity and mortality rates comparable with those of controls (p > 0.05).     

Use of an intraaortic balloon pump in patients with impaired left ventricular function.

Prophylactic use of an intraaortic balloon pump (IABP) prior to open-heart surgery in patients with impaired left ventricular function is still under debate. Patients with left ventricular ejection fraction (LVEF) < 40% were therefore compared according to time of IABP placement, viz. preoperative (n = 56), intraoperative (n = 40) or postoperative (n = 17), and also with patients who did not receive mechanical support despite LVEF < 40% (n = 78). The main indication for preoperative IABP insertion was severely impaired left ventricular function (80%), while patients with intraoperative or postoperative IABP placement mainly presented with low cardiac-output syndrome (70%/53%). Preoperative IABP was associated with a low mortality rate (8.9%), whereas patients with intraoperative or postoperative IABP placement had a high mortality risk and an increased catecholamine requirement. Of the patients scheduled for surgery without prophylactic IABP, 19% required intra- or postoperative insertion. Prophylactic placement of IABP thus reduced the mortality rate as well as the postoperative need for mechanical and catecholamine support. Need for intraoperative IABP insertion was associated with high mortality, whereas the outcome after postoperative IABP placement depended on the indication for the measure.     

Cardiac Pacing Following Surgery for Acquired Heart Disease

Abstract Background: This study is comprised of 3493 consecutive patients who underwent open heart surgery at our institution. Data on all patients were collected prospectively. Methods: In 45 patients (Group P) (1.3%), a permanent pacemaker (PP) was inserted postoperatively. For the purpose of the study, these patients were compared to 3448 patients (Group NP) who did not require insertion of a PP after surgery. Mean follow-up was 33 months (range 1.5 to 66). Results: We found Group P patients were older (64.8 ± 11.0 vs 61.0 ± 11.0 years, p < 0.05), had a higher proportion of elderly (> 70 years) (36% vs 19%, p = 0.01), and of female patients (48.8% vs 22.7%, p < 0.001) compared to Group NP. Group P also had a higher incidence of preoperative rhythm abnormalities (26.6% vs 5.7%, p < 0.0001), redo surgery (13.3% vs 4.6%, p = 0.02), aortic valve surgery (48.8% vs 10.8%, p < 0.001), and tricuspid valve surgery (repair 3, replacement 1) (8.8% vs 0.5%, p < 0.001), in addition to a higher proportion of patients in whom cold (vs warm) blood cardioplegia was used (68.8% vs 52.3%, p = 0.03). Indication for postoperative PP was sick sinus syndrome (SSS) in nine patients; atrial fibrillation in eight patients; atrioventricular block (AVB) in 27 patients; and combined AVB/SSS in 1 patient. There were no operative deaths in Group P. Necessity for PP after heart surgery had a significant impact on resource utilization resulting in prolonged ventilation (3.1 ± 7.5 vs 1.4 ± 3.3 days, p < 0.01), intensive care unit (5.1 ± 10.2 vs 2.5 ± 4.0 days, p < 0.01), and postoperative hospital stay (18.0 ± 13.4 vs 8.1 ± 9.4 days, p < 0.01). Conclusions: By multivariate logistic regression (odds ratio and p value in parentheses), aortic valve surgery (8.23, p = 0.001), the absence of preoperative sinus rhythm (5.60, p = 0.001), postoperative myocardial infarction (3.46, p = 0.024), and female gender (2.52, p = 0.003), were found to be independent predictors for PP requirement post surgery.     

Intraaortic balloon pumping in patients undergoing coronary artery bypass grafting

Beneficial effect of preoperative intraaortic balloon pumping (IABP) treatment in high-risk patients who had open heart surgery have been demonstrated. The purpose of this study is to determine the impact of preoperative IABP use on survival in high-risk patients undergoing coronary artery bypass grafting (CABG). METHODS: Two hundred seventy-seven consecutive patients having CABG at our institution were reviewed. Patients having an IABP were identified retrospectively and grouped into one of 3 groups as follows. Group A (n = 14): preoperative IABP for high-risk urgent or elective cases. Group B (n = 26): preoperative IABP for emergency cases. Group C (n = 6): unplanned intraoperative or postoperative IABP. RESULTS: Forty-six patients had an IABP (16.6% of total). Parsonnet score in group B was significantly higher (p < 0.05). Length of operation for group C was significantly longer (p < 0.05). Overall hospital mortality in the total group of 277 cases was 4.2%. Hospital mortality was 7.1% in group A, 7.7% in group B, and 50% in group C. Hospital mortality in group C was significantly higher (p < 0.01). CONCLUSIONS: The beneficial effect of preoperative treatment with IABP in high-risk patients undergoing CABG was confirmed. This approach resulted in a significantly lower hospital mortality.     

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.     

Beating heart versus conventional single-vessel reoperative coronary artery bypass

BACKGROUND: Reoperative (redo) coronary artery bypass grafting (CABG) with cardiopulmonary bypass (on-pump) is associated with a higher morbidity and mortality than first-time CABG. It is unknown, however, whether CABG without cardiopulmonary bypass (off-pump) may yield an improved clinical outcome over conventional on-pump redo CABG. METHODS: We compared the perioperative outcomes of patients with single-vessel disease who underwent on-pump (n = 41) versus off-pump (n = 91) redo CABG between April 1992 and July 1999. The two groups were similar with respect to baseline characteristics and risk stratification: mean Parsonnet scores were 26 +/- 9 for on-pump versus 24 +/- 8 for off-pump patients (p = nonsignificant). RESULTS: On-pump redo patients had a higher rate of postoperative transfusions (58% on-pump versus 27% off-pump, p = 0.001), prolonged ventilatory support (17% on-pump versus 4% off-pump, p = 0.03), and a higher rate of postoperative atrial fibrillation (29% on-pump versus 14% off-pump, p = 0.04). On-pump redo CABG was also associated with prolonged postoperative length of stay (8 +/- 4 days on-pump versus 5 +/- 2 days off-pump, p < 0.001). In-hospital mortality was significantly higher in on-pump than in off-pump patients (10% versus 1%, p = 0.03). CONCLUSIONS: Single-vessel off-pump redo CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG and an abbreviated hospital stay compared with conventional on-pump redo CABG.     

Expansion of PCI at the Expense of Bypass Surgery Jeopardizes Protection against Premature Death

Prophylactic use of an intraaortic balloon pump (IABP) prior to open-heart surgery in patients with impaired left ventricular function is still under debate. Patients with left ventricular ejection fraction (LVEF) &;lt; 40% were therefore compared according to time of IABP placement, viz. preoperative (n = 56), intraoperative (n = 40) or postoperative (n = 17), and also with patients who did not receive mechanical support despite LVEF &;lt; 40% (n = 78). The main indication for preoperative IABP insertion was severely impaired left ventricular function (80%), while patients with intraoperative or postoperative IABP placement mainly presented with low cardiac-output syndrome (70%/53%). Preoperative IABP was associated with a low mortality rate (8.9%), whereas patients with intraoperative or postoperative IABP placement had a high mortality risk and an increased catecholamine requirement. Of the patients scheduled for surgery without prophylactic IABP, 19% required intra- or postoperative insertion. Prophylactic placement of IABP thus reduced the mortality rate as well as the postoperative need for mechanical and catecholamine support. Need for intraoperative IABP insertion was associated with high mortality, whereas the outcome after postoperative IABP placement depended on the indication for the measure.     

术前置入主动脉内球囊反搏对高危冠状动脉旁路移植术患者预后的影响

目的比较高危冠心病患者术前预防性置入主动脉内球囊反搏(IABP)和被动紧急置入IABP对临床预后的影响. 方法 35例接受冠状动脉旁路移植手术同时需接受IABP置入的患者,根据置入的时机不同分为两组.术前置入组 接受术前预防性置入IABP;对照组术中或术后接受紧急置入IABP.比较两组围术期死亡率、心肌梗死发生率、术后心功能不全和需要正性肌力药物辅助的程度、IABP使用的时间、术后呼吸机辅助时间和重症监护治疗病房(ICU)停留时间. 结果术前置入组围手术期死亡率和心肌梗死发生率分别为11.1%和0%,较对照组低(65.4%,50%;P＝0.007,0.013);两组呼吸机辅助通气时间、IABP使用时间、术后需正性肌力药物辅助时间以及术后平均住ICU时间差别均有显著性意义(P＜0.05). 结论术前预防性置入IABP能降低围术期死亡率、心肌梗死发生率,减少对正性肌力药物的需要量和缩短住ICU时间.     

Complications and frequency of redo antireflux surgery in Denmark: a nationwide study, 1997–2005

Background Outcomes after redo fundoplication (RF) in recurrent gastroesophageal reflux disease (GERD) are debatable, and they may include lower success rates with higher postoperative morbidity and mortality than outcomes after primary fundoplication (PF). However, data from large, nationwide studies are not available. Accordingly, the aim of the present study was to evaluate nationwide Danish data on RF in a nine-year period. Method Data in the period from 1997 through 2005 were extracted from the National Patient Register. The following information was procured: frequency of RF, rate of conversion to open surgery, rate of complications requiring reoperation, and 30-day mortality. Data for RF were compared to PF. Results A total of 2589 fundoplications were performed in 2465 patients. Thus, 113 patients underwent a total of 124 RF (RF rate = 5.0%). Most RF (84.7%) were performed at high-volume departments. Patients who underwent RF were converted to open surgery more often (16.1% vs. 6.1% in PF) (P < 0.0001). The median postoperative hospital stay was 3 days after RF and 2 days after PF (P = 0.96). Following RF 1.6% of the patients had complications requiring surgery compared with 1.3% after PF (P = 0.79), and 30-day mortality was 0.81% after RF compared with 0.45% after PF (P = 0.57). Conclusion This nationwide Danish study showed a low rate of redo fundoplication and a similar morbidity and mortality rate after redo surgery compared with that of primary surgery.     

Comparison of the immediate post-operative outcome of two different myocardial protection strategies: antegrade-retrograde cold St Thomas blood cardioplegia versus intermittent cross-clamp fibrillation

The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.