Emergent coronary artery bypass grafting using percutaneous cardiopulmonary support in a patient with a quadricuspid aortic valve; report of a case

A 63-year-old man was admitted to our hospital for acute myocardial infarction. A cardiac catheter study showed 3 vessels coronary disease. He was treated by percutaneous coronary intervention for a left anterior descending arterial (LAD) lesion. Unfortunately, cardiac tamponade following stenting for LAD was complicated. A percutaneous cardiopulmonary support system was commenced along with an emergent coronary artery bypass grafting to the LAD and obtuse marginal branch. A quadricuspid aortic valve was discovered by an aortotomy and identified as Hurwitz-Roberts classification type b. Blood from the left coronary main trunk had already stopped. Intraaortic balloon pumping was instituted while weaning from the cardiopulmonary bypass. The patient's postoperative course was uneventful and all bypass grafts were sufficient. He was well 1 year after the operation.     

Off-pump coronary artery bypass grafting for unstable angina pectoris combined with hypothyroidism and chronic renal failure; report of a case

Coronary artery bypass grafting for patients with ischemic heart disease and hypothyroidism contains many controversies, and chronic renal failure causes perioperative water-electrolyte balance disorders. We experienced a case of unstable angina pectoris combined with hypothyroidism and chronic renal failure successfully treated by off-pump coronary artery bypass grafting (OPCAB). A 68-year-old man with a history of hypothyroidism and chronic renal failure was hospitalized with chest pain. Cardiac catheterisation revealed a 90% stenosis of segment 3, 11 and right ventricular (RV) branch, 75% stenosis of segment 6 and 50% stenosis of segment 5. His thyroid function was normal with orally administered levothyroxine. OPCAB was performed safely with hemodialysis until a day before operation and hemofiltration from a day after operation, and postoperative course was uneventful.     

The third time coronary artery bypass graft: is the risk justified?

Twenty-one patients undergoing a coronary artery bypass graft operation for the third time were retrospectively reviewed to assess the factors of importance in the management of these patients. The study spans 5.8 years and represents 6.2% of coronary bypass reoperations and 0.6% (21/3500) of total bypass operations during that time. The indication for reoperation was disabling angina pectoris not responsive to medical treatment in 20 patients (95%) and unstable angina pectoris with an intraaortic balloon pump present in one patient (5%). Median sternotomy was used in all and cardiopulmonary bypass in all but one who had an interposition vein graft without cardiopulmonary bypass. Internal mammary artery grafting was used in 86% of patients. There were no operative deaths. One patient died 12 months after his operation. Four patients (19%) required intraaortic balloon pump support postoperatively for up to 6 days. There were no reexplorations for bleeding. One patient required sternal rewiring for an early dehiscence (5%). Respiratory failure occurred in eight patients (38%). Average stay was 4.4 days in the intensive care unit and postoperative hospital stay was 13.7 days. No new Q waves were noted postoperatively. Detailed follow-up was obtained on 18 of the 20 survivors (90%). The two remaining are alive but declined interview efforts. All patients interviewed reported feeling subjectively better than before operation; however 61% of these interviewed continue to have some degree of angina pectoris. One patient has had a late myocardial infarction. This report suggests that the third time coronary bypass can be done with good results when myocardial revascularization is indicated.     

Coronary artery bypass grafting after total esophagectomy

A 69-year-old male with a history of total esophagectomy and substernal placement of the gastric tube for esophageal carcinoma was admitted due to an unstable angina. Cardiac catheterization revealed a severe stenosis just proximal to the left anterior descending coronary artery and a 75% stenosis of the right coronary artery. Intraaortic balloon pumping was started in the catheter laboratory. Off-pump coronary artery bypass grafting was performed through left thoracotomy. The left internal mammary artery could not be utilized as a bypass graft to the left anterior descending artery due to severe substernal adhesion. Percutaneous coronary intervention was selected for the revascularization of the right coronary artery lesion.     

Coronary bypass surgery after renal transplantation

We report, herein, cases of two renal transplantation patients who underwent coronary artery bypass grafting and discuss the perioperative management of this clinical situation. The first case was a 43-year-old male who underwent coronary artery bypass grafting 50 days after renal transplantation, and the second was a chronic case of a 49-year-old male who underwent coronary artery bypass grafting 17 years after renal transplantation. Prior to the operation, the first patient was continuously administered 2mg/kg/day of cyclosporin A with the dosage regulated according to the plasma level. The second patient was administered 50mg/day of cyclophosphamide intravenously instead of an oral dosage of 50mg/day of azathioprine just prior to the operation. In both patients, perfusion pressure during cardiopulmonary bypass was maintained at approximately 80 mmHg in order to obtain optimal urine output. The CD4/CD8 ratio was monitored for indication of graft rejection, but no remarkable changes were observed perioperatively in either patient. Both patients followed a good clinical course and their postoperative renal function was well maintained. The urine output during cardiopulmonary bypass was 300ml and 650ml, respectively. The patients were discharged 15 and 27 days after their operation, respectively. In conclusion, coronary artery bypass grafting can be safely performed in patients who have undergone renal transplantation, if there is appropriate perioperative usage of immunosuppressive agents and maintenance of perfusion pressure during cardiopulmonary bypass.     

Coronary bypass surgery after renal transplantation.

We report, herein, cases of two renal transplantation patients who underwent coronary artery bypass grafting and discuss the perioperative management of this clinical situation. The first case was a 43-year-old male who underwent coronary artery bypass grafting 50 days after renal transplantation, and the second was a chronic case of a 49-year-old male who underwent coronary artery bypass grafting 17 years after renal transplantation. Prior to the operation, the first patient was continuously administered 2 mg/kg/day of cyclosporin A with the dosage regulated according to the plasma level. The second patient was administered 50 mg/day of cyclophosphamide intravenously instead of an oral dosage of 50 mg/day of azathioprine just prior to the operation. In both patients, perfusion pressure during cardiopulmonary bypass was maintained at approximately 80 mmHg in order to obtain optimal urine output. The CD4/CD8 ratio was monitored for indication of graft rejection, but no remarkable changes were observed perioperatively in either patient. Both patients followed a good clinical course and their postoperative renal function was well maintained. The urine output during cardiopulmonary bypass was 300 ml and 650 ml, respectively. The patients were discharged 15 and 27 days after their operation, respectively. In conclusion, coronary artery bypass grafting can be safely performed in patients who have undergone renal transplantation, if there is appropriate perioperative usage of immunosuppressive agents and maintenance of perfusion pressure during cardiopulmonary bypass.     

A successful one stage treatment in angina pectoris and intermittent claudication of both legs

A successful surgical case of concomitant aorto-coronary bypass grafting and aorto-right iliac, left femoral bypass grafting was presented. A sixty-two years old male admitted to our institution with complaints of angina pectoris and intermittent claudication of both legs who had a history of acute inferior myocardial infarction for which emergency percutaneous coronary balloon dilatation was carried out prior to this admission. In this admission, he was found out to have diabetes mellitus moreover and he hoped to have one staged operation for two different type of the disease. After general anesthesia, at first, aorto-right coronary bypass grafting with saphenous vein graft was carried out under cardio-pulmonary bypass, then aorto-right iliac, left femoral bypass grafting with a dacron bifurcated graft was made only with one time of systemic heparinization. His postoperative course was uneventful and discharged in good condition. We conclude that simultaneous aorto-coronary bypass and revascularization of both legs can be done with minimal risk.     

Internal mammary artery graft to pulmonary vasculature fistula: a cause of recurrent angina

Recurrent angina pectoris developed in a 59-year-old man 3 years after coronary artery bypass grafting using the left internal mammary artery. Cardiac catheterization showed a fistula between the left internal mammary artery and the pulmonary vasculature. This is an unusual documented case of postoperative internal mammary artery graft to pulmonary vasculature fistula after coronary artery bypass grafting. Division of this fistulous communication resulted in resolution of the patient's angina.     

Surgical Therapy for Prinzmetal's Variant Angina

Fifty-two patients underwent coronary artery bypass grafting between 1973 and 1979 for variant angina, defined as pain, usually at rest, associated with S-T segment elevation. Only patients with fixed occlusive coronary artery disease, defined as greater than 70% narrowing in diameter, were included. When fixed coronary artery stenosis is present, variant angina—whether presenting as stable, unstable, or postinfarction angina, and regardless of the number of vessels diseased—is effectively treated by myocardial revascularization. Preoperative intraaortic balloon pumping is a useful therapeutic adjunct in the unstable subset refractory to medical therapy. The results of revascularization in patients with Prinzmetal's variant angina and fixed coronary disease were no different from those in patients with classic angina pectoris of comparable clinical categories.     

Severe arrhythmia after gastrectomy in patients with history of coronary bypass graft surgery using right gastroepiploic artery

The authors reported two cases of severe arrhythmia after gastrectomy in the patients with history of coronary bypass grafting (CABG) using the right gastroepiploic artery. The first patient was a 64-year-old man who had undergone CABG involving bypassing between the right coronary artery and the right gastroepiploic artery 5 months before. Partial gastrectomy was performed without significant complications. However, he showed severe bradycardia and low output status with anuria in the intensive care unit (ICU). The second patient was a 74-year-old man who had undergone CABG with the identical method 7 years before receiving partial gastrectomy. Although, surgery was performed with intraaortic balloon pumping for his mild heart failure, no other complication was observed during operation and ICU stay. Immediately after being moved to the ward on postoperative day 3, recurrent ventricular tachycardia occurred. Finally, the patient was implanted with an automatic defibrillator.     

Left ventricular reconstruction on the beating heart with retrograde coronary perfusion for repair of a left ventricular aneurysm associated with aortic regurgitation: report of a case

A 67-year-old male was undergoing hemodialysis for renal failure. He had carotid stenosis, multiple liver cysts with impaired liver function, and mild aortic regurgitation in addition to a left ventricular aneurysm with reduced left ventricular function. We used intraaortic balloon pumping with a view to maintaining cerebral and hepatic blood flow during extracorporeal circulation. However, this procedure risked increased regurgitation at the aortic valve. Therefore, after aortic cross-clamping, we performed the left ventricular reconstruction while cardiac pulsation was maintained by retrograde coronary perfusion using normothermic oxygenated blood. Coronary artery bypass grafting followed after the cross-clamp was released. The patient's postoperative progress was smooth and he was discharged on 14th postoperative day.     

39例非体外循环下冠状动脉搭桥术的经验

目的总结我院4年来非体外循环冠状动脉搭桥术的临床结果与经验。方法2000年7月_2004年7月,在我科收治2例严重冠心病中,成功的施行非体外循环冠状动脉搭桥术39例,其中青年例术前使用主动脉球囊反搏（IABP）,术中均采用Octopus稳定器。另外3例患者因术中血流动力学不稳定的转体外循环下完成手术。结果全组无1例围手术期死亡,术后心绞痛症状均消失,心功能得到不同程度改善。结论非体外循环冠状动脉搭桥术是一种安全可行,是治疗冠心病的良好方法。     

Coronary artery spasm after off-pump coronary artery bypass grafting

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.     

Fibrillation in patients subjected to coronary artery bypass grafting

OBJECTIVE: Atrial fibrillation is the most frequently encountered postoperative arrhythmic complication after coronary artery bypass grafting. Ischemic preconditioning has proved a potent endogenous factor in suppressing ischemia-reperfusion-induced arrhythmias. The protective effect of ischemic preconditioning on atrial fibrillation after coronary artery bypass grafting has not been studied. The purpose of the present study was to investigate whether ischemic preconditioning had an effect on postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. METHODS: Eighty-five patients undergoing coronary artery bypass grafting were randomized into ischemic preconditioning and control groups. Holter data from 24-hour electrocardiography were collected 1 day before the operation to the second postoperative day. Atrial fibrillation was registered as positive if any atrial fibrillation event occurred. RESULTS: The overall incidence of postoperative atrial fibrillation and sustained atrial fibrillation was 34.1% and 27.1%, respectively. The occurrence of atrial fibrillation was significantly lower in the ischemic preconditioning group (21.4% in patients undergoing ischemic preconditioning and 46.5% in control subjects, P =.015). Preoperative recent unstable angina did not influence the incidence of atrial fibrillation. Patients with atrial fibrillation had longer intensive care unit stays and compromised postoperative hemodynamic outcomes. Binary logistic regression analysis showed that ischemic preconditioning, preoperative mean heart rate, and postoperative pulmonary capillary wedge pressure were the independent predictors of atrial fibrillation. CONCLUSIONS: Postcoronary artery bypass grafting atrial fibrillation is associated with more complicated postoperative outcome. Higher preoperative heart rate and postoperative pulmonary capillary wedge pressure were the independent predictors of atrial fibrillation. Recent unstable angina is not related to the occurrence of postcoronary artery bypass grafting atrial fibrillation. Ischemic preconditioning significantly suppresses postcoronary artery bypass grafting atrial fibrillation, suggesting that ischemic preconditioning can be used as an effective prophylactic method for postoperative atrial fibrillation.     

Concomitant lobectomy for lung cancer under intraaortic balloon pumping and coronary bypass grafting

A 71-year-old man was admitted because of an abnormal shadow on the chest X-ray film. Chest computed tomography (CT) revealed a tumor in the right upper lobe. The diagnosis of lung cancer was made by transbronchial lung biopsy. He had suffered an infarction of the inferior myocardial wall at the age of 55 years. Preoperative coronary angiography revealed total occlusion of segment 1, 75% stenosis of segments 5 and 6, and 90% stenosis of segment 13. Since these coronary lesions could cause perioperative and postoperative myocardial infarction, the patient was scheduled to undergo surgery of both the heart and lung in a one-stage operation. Under intraaortic balloon pumping (IABP), we performed a right upper lobectomy of the lung, and coronary artery bypass grafting with cardiopulmonary bypass through median sternotomy. During the lobectomy and first postoperative day, a stable circulation was achieved with IABP. The postoperative course was uneventful. At present, that is 33 months after the operation, the patient presents no sighs of recurrence of lung cancer and has not suffered any anginal attack during follow-up. Lung cancer and coronary artery disease can be treated simultaneously by this procedure.     

非体外循环冠状动脉旁路移植术153例体会

目的　探讨非体外循环冠状动脉旁路移植术无手术死亡的治疗体会。方法　回顾性分析近 4年来 15 3例非体外循环冠状动脉旁路移植术的临床资料。结果　全组无手术死亡。平均搭桥 3 .1支 ,无围手术期心肌梗死、呼吸衰竭、肝肾功能衰竭等并发症 ,92 %患者术后 4～ 6h拔除气管内插管 ,5 6%患者未输血 ,术后心绞痛均消失。结论　非体外循环冠状动脉旁路移植术安全、有效 ,术后并发症少 ,正确掌握其手术适应证、手术配合、手术技巧和围手术期处理 ,是确保手术疗效的关键。     

Acute type A aortic dissection, developed shortly after aortic valve replacement and coronary artery bypass grafting

We experienced a case of acute type A aortic dissection shortly after a cardiac operation. A 73-year-old man underwent aortic valve replacement and coronary artery bypass grafting for aortic regurgitation and angina pectoris. Aortic valve was tricuspid and the ascending aorta was mildly dilated in preoperative studies. The postoperative computed tomography (CT) revealed aortic dissection, from the ascending aorta to the arch of aorta, although the patient was asymptomatic. Reoperation for the aortic dissection was performed on the 22nd post operative day. Re-do sternotomy was safely carried out prior to heparinization. Under hypothermic circulatory arrest with femoral arterial and venous cannulations, the ascending aorta was replaced and re-implantation of the saphenous vein graft was carried out. The postoperative recovery was uneventful and he was discharged on the 17th postoperative day.     

非体外循环下冠状动脉旁路移植术治疗左冠状动脉主干合并3支血管病变

目的总结非体外循环冠状动脉旁路移植术(OPCAB)对左冠状动脉主干合并3支血管病变患者的治疗经验及体会。方法对33例左冠状动脉主干合并3支血管病变患者施行了OPCAB,用左乳内动脉作为移植血管与左前降支进行吻合,大隐静脉作为移植血管分别与回旋支、右冠状动脉/后降支、对角支和钝缘支进行吻合。结果每例患者行旁路血管移植2～5支,平均3.4支。无手术死亡,无围手术期心肌梗死、呼吸衰竭、肝肾功能衰竭等严重并发症,术后心绞痛均消失。结论OPCAB治疗左冠状动脉主干合并3支血管病变的高危冠心病患者是可行、有效的,手术损伤小;而积极的术前准备、主动脉内球囊反搏的应用、正确的手术方法和配合、建立一支熟练快速的应急队伍是确保手术成功的关键。     

Recent unstable angina and off-pump coronary artery bypass grafting is not related to postoperative atrial fibrillation

OBJECTIVE: Atrial fibrillation (AF) is the most frequently encountered postoperative arrhythmic complication after coronary artery bypass grafting (CABG). The purpose of the present study was to investigate the incidence and predictors of postoperative AF in patients with stable and unstable angina pectoris undergoing on-pump and off-pump CABG procedures. DESIGN: One hundred and seventeen stable, unstable on-pump and off-pump CABG patients were included in the present study. Holter data were collected 1 day before the operation to the 2nd postoperative day. AF was registered as positive if any AF event occurred. RESULTS: The overall incidence of postoperative AF and sustained AF was 31.6 and 25.6%, respectively. Postoperative AF incidences in stable on-pump, unstable on-pump and stable off-pump patients were 29.5, 39.0 and 25%, respectively (p = 0.412). Patients with AF had compromised postoperative haemodynamic function, greater need of inotropic support and antiarrhythmic medication, and longer intensive care unit (ICU) stays. CONCLUSION: Post-CABG AF is associated with more complicated postoperative outcome. Recent unstable angina and off-pump procedure is not related to the occurrence of post-CABG AF.     

Repeat coronary artery bypass grafting

In 1981-1989 we performed repeat coronary artery bypass grafting on 42 men and 10 women (mean age 55 years) with angina pectoris recurring on average 27 months after the primary operation. The cause was occlusion or stenosis of vein grafts alone (59%) or in combination with progression of native coronary atherosclerosis (31%) or progression in the native circulation without graft failure (10%). Complications at the repeat operation included five lesions of the right ventricle and five lesions of patient grafts. The 30-day mortality was 3.8% (95% confidence limits 0.5-13.2%). Survival after observation averaging 2 1/2 years was 92.3% (95% confidence limits 81.5-97.9%). Angina pectoris was completely relieved after the operation in 48% of the patients, lessened in 35% and unchanged in 17%. Although repeat coronary artery bypass grafting carries heightened mortality and morbidity, and the results are less satisfactory than after first-time bypass, the operation can be worthwhile.