Long-term exercise performance after percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

In our first 169 consecutive patients admitted to undergo percutaneous transluminal coronary angioplasty (PTCA) serial bicycle ergometric exercise sessions were scheduled to assess long-term-exercise performance. In 160 of these 169 patients (95%) an average of seven ergometric measurements were available during a mean follow-up period of 29 months (range 1 to 60 months). Two groups were formed. One consisted of 132 patients in whom PTCA was successful and the other consisted of 28 patients with failure of PTCA who subsequently underwent coronary artery bypass grafting (CABG) either on an emergency basis (12 patients) or as an elective procedure (16 patients). Exercise performance was expressed as work capacity in watts according to the highest completed exercise stage. In the successful PTCA group the actual work capacities increased from 74 +/- 42 W (mean +/- SD) before PTCA to 122 +/- 47 W at the most recent follow-up examination. In patients who underwent emergency or elective CABG the respective figures were 73 +/- 34 or 65 +/- 37 W before surgery and 120 +/- 41 or 119 +/- 41 W at the most recent follow-up examination (p less than .005 for all preprocedure to postprocedure comparisons). Successful PTCA and CABG after failed PTCA improve work capacity significantly. Comparison of our results with those of surgical studies indicates that a failed attempt at PTCA before CABG does not compromise the functional outcome of the operation, regardless whether it is done on an emergency or on an elective basis.     

Upper gastrointestinal haemorrhage following coronary artery bypass grafting

Background: Upper gastrointestinal (UGI) bleeding is a relatively common and potentially fatal complication of coronary artery bypass graft (CABG) surgery. However, little is known of this problem, including its incidence, predisposing factors and safety of endoscopy in these patients. Aim: To document the incidence, site, predisposing factors and outcome of UGI bleeding following CABG surgery. Also, to assess the safety of UGI endoscopy in these patients. Method: Retrospective study of UGI haemorrhage following CABG at one institution between 1976 and 1991. Results: Fifty-five of 10,573 patients (0.5%) suffered a major UGI haemorrhage (as defined by need for transfusion or presence of melaena or haematemesis associated with hypotension). Of 51 patients undergoing endoscopy or laparotomy, 42 (82%) bled from duodenal ulceration. Five patients bled from gastric ulcers and one each from oesophagitis and Mallory Weiss tear. Nine patients underwent endoscopic therapy, which initially arrested haemorrhage in eight patients. However, three patients rebled and required surgery. Eight patients underwent surgery as initial therapy, resulting in an overall surgical rate of 20%. One patient died due to multi system failure following surgery. There were no complications from endoscopy. Patients who bled were more likely to have received inotropic support post-operatively prior to the haemorrhage (p < 0.05) and tended to be older than controls (mean age 65.6 years vs 58.7 years, p < 0.01). Twenty-one of the patients (38%) who bled had a past history of peptic ulceration or dyspepsia compared with 9% of controls (p < 0.001). Seven (12.5%) had previously bled from peptic ulceration. Patients who bled were less likely to have received H₂-receptor antagonists in the perioperative period than controls (4%vs 20%, p< 0.05). Conclusion: Upper GI haemorrhage following CABG is relatively frequent. It is usually secondary to duodenal ulceration. Endoscopy is a safe procedure in this patient group. Mortality did not differ between index patients who suffered a UGI haemorrhage and controls undergoing CABG who did not bleed.     

Coronary-subclavian steal syndrome following coronary artery bypass grafting

Angina pectoris resulting from the coronary-subclavian steal syndrome is a rare phenomenon with only 10 previously reported cases. However, with the increasing use of the internal mammary artery in the coronary artery bypass graft (CABG) procedure it may be encountered more frequently in the future. We report our recent experience with coronary-subclavian steal syndrome after CABG with 2 patients in whom complete relief from angina pectoris was obtained following bypass of a proximal subclavian artery occlusion in one patient and improvement of angina in the other. A review of the relevant literature is also presented.     

Upright bicycle exercise echocardiography after coronary artery bypass grafting

Upright bicycle exercise echocardiography and coronary angiography were performed in 42 patients from 1 month to 15 years (mean 6.3 years) after coronary artery bypass grafting (CABG) to determine if exercise-induced wall motion abnormalities could be correlated with the presence and location of nonrevascularized vessels. Nonrevascularized vessels were defined as obstructed vessels without grafts, obstructed grafts or native vessels obstructed distal to bypass graft insertion. Adequate quality echocardiograms were recorded at rest, peak exercise and after exercise in 38 patients (90%). Rest and postexercise echocardiograms were adequate in 3 others. Only 1 patient was excluded from analysis for inadequate peak and postexercise echocardiograms. Exercise-induced wall motion abnormalities were present in 33 of 35 patients (94%) who had 1 or more nonrevascularized vessels and these abnormalities were absent in 5 of 6 (83%) who had all vessels revascularized. Wall motion abnormalities were localized to the territory of the left anterior descending (LAD) artery or to a combined right (R) coronary-left circumflex (LC) region of circulation. Exercise-induced wall motion abnormalities were present in 24 of 27 LAD artery regions (89%) and 23 of 26 R-LC regions (88%) that had nonrevascularized vessels. These abnormalities were absent in 13 of 14 LAD regions (93%) and in 12 of 15 R-LC regions (80%) that had only revascularized vessels. Upright bicycle exercise echocardiography was successfully performed after CABG. The technique detected and accurately localized nonrevascularized and revascularized vessels.     

Positive end-expiratory pressure following coronary artery bypass grafting

Pulmonary dysfunction commonly follows open heart surgery. To evaluate the effects of positive end-expiratory pressure (PEEP) upon the course and severity of impaired oxygen transfer and roentgenographic evidence of atelectasis after coronary artery bypass grafting (CABG), we randomly assigned 44 patients to positive pressure ventilation and 0, 5, or 10 cm H2O PEEP. Study groups did not differ with respect to preoperative P(A-a)O2 or time on cardiopulmonary bypass. We observed a significant reduction of P(A-a)O2 during positive pressure ventilation with 10 cm H2O PEEP and FIO2 = 0.6 (182 +/- 6 vs 135 +/- 7 mm Hg, p less than .005). Following extubation, P(A-a)O2 measurements of the three groups did not differ when compared 24, 48, 72, 96, or 120 hours after surgery. Roentgenographic atelectasis scores did not differ on the fifth postoperative day. Five days after CABG, P(A-a)O2 exceeded preoperative P(A-a)O2 (29 +/- 1 vs 18 +/- 1 mm Hg, p less than .001), although the roentgenographic distances from hemidiaphragm to lung apex were unchanged (21.2 +/- 0.9 vs 22.0 +/- 0.9 cm). We conclude that routine PEEP improves pulmonary oxygen transfer but, once discontinued, PEEP offers no sustained beneficial effect upon impaired oxygen transfer or roentgenographic evidence of atelectasis following CABG.     

Changes in bone mineral and body composition following coronary artery bypass grafting in men

This study investigated bone mineral and body composition changes after coronary artery bypass grafting (CABG) in men. Twenty-six men 50 to 79 years of age underwent CABG for multivessel coronary disease. Dual-energy x-ray absorptiometry was performed before surgery and 3 months and 1 year after treatment to assess bone mineral content (BMC), bone mineral density (BMD), and body composition. Through 3 months after treatment, BMD decreased at the total body, arms, and pelvis. BMC of the arm decreased and losses at the total body and legs approached significance. Fat-free mass decreased in the arms and total body but not in the legs. Neither total body nor regional fat mass changed. At the 1-year follow-up visit, 15 of the initial 26 subjects returned for dual-energy x-ray absorptiometry. Compared with before treatment, BMD decreased at the total body and legs, whereas losses at the arms approached significance. Arm BMC decreased over the 1-year post-treatment period. No changes were observed in body composition. In conclusion, CABG and the ensuing convalescence period results in considerable arm bone mineral losses through 1 year after treatment.     

Rescue percutaneous coronary intervention immediately following coronary artery bypass grafting

Perioperative graft failure after coronary artery bypass graft (CABG) can result in acute myocardial infarction with dire clinical consequences. We report a case of rescue percutaneous coronary intervention immediately after unsuccessful CABG. This approach salvaged the patient from cardiogenic shock and should be recognized as a viable alternative to immediate reoperation for certain patients.     

Coronary artery surgery: conventional coronary artery bypass grafting versus off-pump coronary artery bypass grafting

PURPOSE OF REVIEW: Coronary revascularization has become the principal treatment modality in patients with severe coronary artery disease. The broader application of percutaneous coronary interventions in patients with multivessel disease and the recent introduction of drug-eluting stents have both lead to a decline in the number of patients referred for surgical revascularization. Conventional coronary artery bypass grafting using cardiopulmonary bypass is an excellent treatment, however less invasive surgical approaches such as off-pump coronary artery bypass grafting have appeared in the past few years. The exact role of off-pump coronary artery bypass grafting is still vaguely defined and being critically evaluated. Our aim is to provide an objective review of the recent literature in regard to surgical outcomes. RECENT FINDINGS: A critical review of all relevant clinical series from May 2003 to May 2005 was conducted. Current prospective data suggests that both techniques have similar rates of mortality, in regard to morbidity, multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. The incidence of postoperative myocardial infarction does not appear to differ between techniques. When analyzed carefully, the results presented herein seem to indicate that both techniques provide similar rates for long-term patency and freedom from surgical reintervention. SUMMARY: Coronary artery bypass grafting and off-pump coronary artery bypass grafting are both safe and beneficial in patients with multivessel coronary artery disease. It appears that elderly patients with additional co-morbid risk factors may benefit most from off-pump coronary artery bypass grafting. It has become increasingly apparent that off-pump coronary artery bypass grafting can be performed safely in reference centers.     

冠状动脉旁路移植术后胸部切口感染的治疗

目的探讨冠状动脉旁路移植术后胸部切口感染的原因和治疗。方法分析321例冠状动脉旁路移植术后24例胸部切口感染患者行二期清创缝合或二次手术资料。结果本组24例患者均一期愈合，痊愈出院，随访1—96个月，无胸部切口相关并发症。结论冠状动脉旁路移植术后胸部切口感染的原因是多方面的，行二期清创缝合或二次手术，可获良好效果。     

Changes in jugular venous flow velocity after coronary artery bypass grafting

The factors underlying postoperative jugular venous flow velocity and pulse contour changes were studied in 25 patients undergoing coronary artery bypass grafting. Before operation, all patients had normal right-sided cardiac hemodynamics, normal jugular pulse contours and normal jugular venous flow velocity patterns, i.e., systolic flow (SF) velocity greater than diastolic flow (DF) velocity. After operation, jugular venous flow velocity was abnormal in 24 patients (SF = DF in 14 and SF less than DF in 10). Neither the right-sided cardiac pressures after the operation nor any of the perioperative factors examined had any bearing on these flow alterations. Postoperative right ventricular ejection fraction was normal in all 5 patients with SF greater than DF and SF = DF flow patterns (mean +/- standard error of the mean 48 +/- 3%). It was significantly depressed in all 6 patients with SF less than DF flow pattern (34 +/- 1%, 2p less than 0.001). These findings suggest that the right atrium behaves as a conduit rather than a capacitance chamber. However, the postoperative abnormal flow pattern of SF less than DF as opposed to SF = DF indicates the additional presence of right ventricular dysfunction. The implications of these observations for the clinical assessment of right ventricular function in the postoperative patients are discussed.     

186例老年冠心病患者是、否体外循环下冠脉旁路移植术的比较

目的:比较老年冠心病患者体外循环与非体外循环下冠状动脉旁路移植术的疗效。方法:A组选择87例65岁以上的老年患者在体外循环下行冠状动脉旁路移植术(CCABG);B组选择79例65岁以上的老年患者在非体外循环下行冠状动脉旁路移植术(OPCABG)。结果:B组死亡率低于A组(P<0.05),术后胸腔引流量明显少于A组(P<0.05)。结论:老年冠心病患者行冠状动脉旁路移植术是安全的。     

非体外循环冠状动脉旁路移植术后早期认知功能障碍的临床研究

目的:研究非体外循环冠状动脉旁路移植术(OPCABG)术后早期认知功能障碍(POCD)发生的危险因素。方法:收集2012年1月至2015年1月期间,在北京安贞医院住院行OPCABG的患者127例,根据术后是否出现POCD分为认知障碍组62例和非认知障碍组65例,分析OPCABG后POCD发生的危险因素。结果:POCD组颈动脉重度狭窄或闭塞的比率高于未发生POCD组(P0.05)。多因素Logistic回归分析结果显示,颈动脉重度狭窄或闭塞(OR=3.500,95%CI:1.177~10.403,P=0.024)是POCD发生的独立危险因素。结论:颈动脉重度狭窄或闭塞是POCD的独立危险因素,术前应加强对颈动脉狭窄的筛查,谨慎评估手术风险,旨在减少术后POCD的发生。     

小切口与胸骨正中切口在冠状动脉旁路移植手术中的比较

目的:比较左胸小切口冠状动脉旁路移植手术(MIDCAB)与常规正中切口冠状动脉旁路移植手术(CABG)的临床效果。方法:2012年10月至2015年12月,采用左胸小切口取左乳内动脉(LIMA)心脏不停跳CABG术45例和常规正中开胸CABG手术50例。比较术前基本情况、手术时间、出血量、术后疼痛评分、围术期心肌梗死、死亡等指标;所有患者均在术后1年时进行随访,比较术后1年的吻合口再狭窄、心绞痛、心肌梗死、脑卒中及死亡等重要终点事件发生率。结果:入选两组患者术前一般情况无显著差别。两组患者均成功施行不停跳CABG手术,围术期均无死亡。MIDCA组具有手术时间短,围术期出血少等优点。但MIDCAB组术后疼痛程度较常规正中切口CABG组大。两组在围术期心肌梗死发生、切口愈合不良发生率上差异无统计学意义。随访1年时,两组患者在心绞痛、心肌梗死、死亡、脑卒中、吻合口再狭窄等终点事件差异均无统计学意义。结论:MIDCAB术具有与传统正中切口手术一样的近中期效果,MIDCAB术安全可行,值得推广。     

非体外循环下冠状动脉搭桥术后甲状腺激素水平的变化

目的:评价非体外循环下冠状动脉搭桥术后甲状腺激素水平的变化,研究其临床意义。方法:选取我院2006年6月至2006年12月非体外循环下冠状动脉搭桥术患者8例A组,同时选取体外循环(cardiopulmonary bypass,CPB)下冠状动脉搭桥术患者15例为B组,分别测定2组术前及术后一周血浆甲状腺激素和促甲状腺激素(TSH)的浓度。结果:在CPB下冠状动脉搭桥术的患者其三碘甲状腺原氨酸(T3)、游离三碘甲状腺原氨酸(FT3)术后一周呈下降低趋势P<0.05,甲状腺素(T4)、游离甲状腺素(FT4)和TSH手术前后差异无显著性,而非CPB下冠状动脉搭桥术的患者T3和FT3术后一周略有下降,但与术前相比差异无显著性(P>0.05)。结论:在CPB下冠状动脉搭桥手术对甲状腺激素的代谢有影响,术后表现为低T3综合征,而非CPB下冠状动脉搭桥手术对甲状腺激素水平的影响较小。提示非CPB下冠状动脉搭桥手术对机体垂体-甲状腺轴的影响相对小、安全性高、预后更好。     

体外循环与非体外循环冠状动脉旁路移植术早期疗效分析

目的:探讨体外循环冠状动脉旁路移植术(CCABG)和非体外循环冠状动脉旁路移植术（OPCABG）早期疗效的差异。方法: 采集自2003年10月~2008年1月我院单纯冠状动脉旁路移植术5325例临床资料,分为CCABG组（343例）与OPCABG组（4 982例）。对两组患者各项术前因素、术中因素、手术死亡率及并发症进行比较。结果: OPCABG组实际手术死亡率（1.7％）明显低于CCABG组（6.7％）,P<0.01;术后二次开胸止血、肾功能不全等并发症的发生率及ICU停留时间、呼吸机辅助时间、术后住院时间都低于CCABG组（P<0.05,P<0.01）。风险调整后CCABG组手术死亡率仍高于OPCABG组6个百分点,术后并发症的发生率均略高于OPCABG组（P<0.05）。结论: CCABG与OPCABG早期临床疗效均令人满意,后者更好一些。     

冠状动脉旁路移植术前后心肌营养素-1的变化

目的:观察冠心病(coronary heart disease,CHD)患者,行冠状动脉旁路移植术(coronary artery bypass graft,CABG)治疗前后,血清心肌营养素-1(cardiotrophin-1,CT-1)的变化及意义。方法:选择60例成功接受CABG的CHD患者,分别于术前、术后1d、1w测定血清CT-1浓度,于术前及术后1w行超声心动图(ultrasonic cardiogram,UCG)检查测定左心室射血分数(LVEF)、左心室舒张末期容积指数(LVEDVI)和左心室收缩末期容积指数(LVESVI)。结果:①CHD患者术后1d CT-1较术前增高(P0.05);②CHD患者术后1w,CT-1明显降低(P0.05),且UCG各参数明显改善(P0.05)。结论:CHD患者血清CT-1升高,且CT-I与心功能关系密切,检测CT-1对CHD患者的治疗和心功能的评价有一定价值。     

Atenolol for the prevention of arrhythmias following coronary artery bypass grafting

Seventy patients undergoing aortocoronary bypass grafting were randomized, double-blind, to receive either atenolol or placebo. There were 35 patients in each group. Patients received either atenolol 5 mg intravenously or matching placebo within 3 h of the completion of surgery. A second intravenous dose was administered 24 h following the first and then atenolol 50 mg orally or matching placebo was given for six days. Continuous Holter monitor recordings were obtained for the 24 h immediately preoperatively and continuously for eight days postoperatively. No patient received any antiarrhythmic drug preoperatively. Patients who required pharmacological intervention for the management of postoperative arrhythmias were withdrawn as treatment failures. Holter monitor analysis continued for 24 h following withdrawal of a treatment failure. All patients were analyzed according to the intention-to-treat principle. Both groups were comparable with respect to age, sex, severity of coronary artery disease, left ventricular ejection fraction, preoperative use of beta-blockers, bypass time, aortic cross-clamp time, number of grafts per patient and frequency of preoperative arrhythmias. Arrhythmia analysis was done manually. Supraventricular arrhythmias (atrial tachycardia, atrial fibrillation and atrial flutter) were classified as either mild (less than 0.5 mins, less than 140 beats/min), moderate (0.5 to 30 mins, 140 to 180 beats/min), or severe (longer than 30 mins, more than 180 beats/min). Ventricular arrhythmia analysis was performed with respect to isolated PVCs, couplets, triplets and episodes of nonsustained ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)