Coronary angioplasty in patients with prior coronary artery bypass surgery: all prior coronary artery bypass surgery patients and patients more than 5 years after coronary bypass surgery

Percutaneous transluminal coronary angioplasty (PTCA) has been used successfully in patients who have had prior bypass surgery (CABG) as a means of revascularizing the myocardium and avoiding repeat myocardial revascularization. However, angioplasty has been considered inappropriate as a means of dilating old saphenous vein grafts. The first section of this article details the authors' experience with PTCA of prior CABG patients, and the second section discusses the results of PTCA in the subset of patients 5 or more years after their last coronary bypass surgery. These data may make individuals rethink the appropriateness of PTCA in old saphenous vein grafts.     

Structured postoperative teaching and knowledge and compliance of patients who had coronary artery bypass surgery

A convenience sample of two comparable groups of patients who had coronary artery bypass surgery was studied to assess the effectiveness of a structured teaching guide used by nurses in educating the patient and his family about normal postoperative recovery. Preoperative health assessments were performed on 64 patients, and risk factors for heart disease were identified for each individual. One group was educated by an unstructured method; the other group received structured teaching with the use of a guide developed by nurses experienced in recovery after open heart surgery. Knowledge was assessed before instituting teaching and on discharge from the hospital. All patients were again assessed 6 weeks after discharge for postoperative health and compliance with their health risk factors identified earlier. An analysis of variance with repeated measures revealed that both groups had higher total knowledge scores after surgery. Most postoperative health behaviors (angina, smoking, hypertension, and diet) were comparable between groups. However, those patients who had structured postoperative teaching walked more blocks after surgery (mean = 15.61) than those patients who received routine teaching (mean = 7.00) (p less than 0.005), although these two groups were not equivalent before surgery. In addition, the patients who had structured teaching had higher total compliance scores (mean = 86.8) than those who had unstructured teaching (mean = 79.5) (p less than 0.05). Therefore although structured teaching may not have initially affected patient's knowledge, it may have had an impact on their compliance with postoperative health behaviors.     

Gene polymorphisms in patients below 35 years of age who underwent coronary artery bypass surgery

OBJECTIVE: Genetic bases for novel prothrombotic, inflammatory risk factors may play a role in the early onset of coronary artery disease. METHODS: Twenty-one patients below 35 years of age who underwent coronary bypass grafting between 2002 and 2004 constituted the study group and were compared with 50 healthy, age and sex-matched controls. Gene analysis for genetic polymorphisms of angiotensin-converting enzyme, prothrombin G20210A, tumour necrosis factor-alpha G308A, factor V Leiden and interleukin-6 genes was carried out. RESULTS: The control group was 98% homozygous for the factor V Leiden GG allele and 2% heterozygous for the GA allele. On the other hand, the study group was 76.2% homozygous for the GG allele, and 23.8% heterozygous for the GA allele (P<0.05). Homozygosity for factor V Leiden mutation (AA) was not encountered in either group. With regard to interleukin-6, 70.0% of the control group demonstrated homozygosity for the GG allele and 30.0% showed heterozygosity (GC). The study group was 52.4% homozygous for the GG allele and heterogenicity was similar in this group (28.6% GC). On the other hand, 19.0% of this group demonstrated CC homogenicity (P<0.05). No difference was observed with regard to gene polymorphisms. CONCLUSIONS: Gene polymorphisms with regard to prothrombotic factor V Leiden mutation and inflammatory marker interleukin-6 may play a role in the pathogenesis of early-onset coronary artery stenosis in patients below 35 years of age.     

Arterial blood gases after coronary artery bypass surgery.

Coronary artery bypass graft (CABG) surgery adversely affects arterial blood gas (ABG) determinations. The purposes of this study were to assess serial changes in ABGs following bypass surgery and identify factors that may influence these changes. Room air ABGs were obtained preoperatively and on days 1, 2, 4, 6, and 8 postoperatively on 125 patients undergoing bypass surgery. Fifty-five patients (saphenous vein grafting [SVG] group) had only SVG grafting while 70 (internal mammary artery [IMA] group) received one (60 patients) or two (10 patients) IMA grafts in addition to the SVG grafts and were subjected to pleurotomy. The mean preoperative values (+/- SD) were as follows: PaO2, 75.1 +/- 7.7 mm Hg, P(A-a)O2, 20.9 +/- 7.5 mm Hg; PaCO2, 33.6 +/- 4.1 mm Hg; pH, 7.43 +/- 0.04; hemoglobin, 14.8 +/- 1.4 g/dl; and hematocrit, 44.2 +/- 3.9 percent. There was a large decrease in the PaO2 postoperatively. The nadir for the PaO2 (55.7 +/- 6.6 mm Hg) occurred on the second postoperative day. Eight days postoperatively, there were still significant abnormalities; the PaO2 was 65.7 +/- 7.3 mm Hg, the P(A-a)O2 was 33.2 +/- 8.8 mm Hg; the hemoglobin was 10.5 +/- 1.4 g/dl; and the hematocrit was 31.7 +/- 4.0 percent. The decrease in the PaO2 was particularly noteworthy given the large decrease in the hemoglobin and hematocrit. The changes in the PaO2 were not significantly correlated with the age, number of grafts, pump time, length of anesthesia, or endotracheal intubation or smoking history. Immediately postoperatively, changes were similar in both groups (p > 0.05); on the second postoperative day, the PaO2 had decreased 26.9 percent in the SVG group and 25.5 percent in the IMA group. However, the postoperative abnormalities resolved more slowly in the IMA group (p < 0.05). These observations suggest that the additional trauma to the lungs and chest wall in the IMA group (pleurotomy, the placing of pleural drains, etc) will result in a longer recovery time in the IMA group than in SVG group.     

老年冠心病患者非体外循环冠状动脉旁路移植术后新发心房颤动的危险因素分析

目的探讨老年冠心病患者非体外循环冠状动脉旁路移植术后新发心房颤动的危险因素。方法回顾性分析159例老年非体外循环冠状动脉旁路移植术后患者资料,根据术后是否新发心房颤动分为两组,分析冠状动脉病变情况、旁路移植血管支数、术后电解质变化、循环血容量变化、抗心律失常药物使用等因素与术后新发心房颤动的相关性。结果 35例患者术后出现心房颤动,发生率22.01%(35/159)。在单因素分析中,心房颤动组患者与非心房颤动组患者比较,年龄[(66.9±5.0)岁比(64.9±3.7)岁,P=0.009]、术前射血分数(42.66%±7.51%比45.94%±8.46%,P=0.039)、术前血氧饱和度(Sp O2,89.67%±6.14%比92.00%±5.34%,P=0.029)、旁路移植血管支数[(3.3±1.4)支比(2.7±1.2)支,P=0.017]、术前3 d脑钠肽(BNP)水平[(850.88±711.55)pg/ml比(523.20±682.57)pg/ml,P=0.014]、术后3 d BNP水平[(2 276.45±1 281.82)pg/ml比(1 444.47±1 163.38)pg/ml,P=0.000]、术后3 d血钾[(3.59±0.24)mmol/L比(4.01±0.62)mmol/L,P=0.000]、术后3 d血钙[(2.31±0.21)mmol/L比(2.23±0.07)mmol/L,P=0.000]、住院天数[(21.5±5.4)d比(19.4±4.8)d,P=0.026]等指标差异均有统计学意义。Logistic回归分析显示,年龄(OR:0.87,95%CI:0.776~0.976)、合并心脏瓣膜病(OR:0.149,95%CI:0.034~0.658)、术前Sp O2(OR:1.092,95%CI:1.012~1.117)、旁路移植血管支数(OR:0.543,95%CI:0.349~0.845)、术后3 d BNP水平(OR:1.000,95%CI:0.999~1.000)、术后3 d血钾(OR:3.842,95%CI:1.227~12.029)、术后3 d血钙(OR:0.007,95%CI:0.000~0.520)与术后新发心房颤动具有显著相关性(均为P<0.05)。结论年龄>65岁、合并心脏瓣膜病、术前Sp O2<90%、旁路移植血管支数>3支、围术期电解质紊乱是老年非体外循环冠状动脉旁路移植术后新发心房颤动的危险因素。     

Screening for subclavian artery stenosis in patients who are candidates for coronary bypass surgery.

We prospectively evaluated 59 patients who were deemed candidates for coronary bypass surgery after coronary artery angiography for subclavian artery narrowing, which could compromise the ipsilateral internal thoracic artery graft. Bilateral arm blood pressure (BP) measurements, auscultation for supraclavicular or cervical bruits, and questioning about cerebrovascular ischemic symptoms were compared to brachiocephalic-subclavian arteriography. One neurologic complication occurred during arteriography. An upper extremity BP difference of > or = 15 mm Hg identified all patients with > or = 50% subclavian artery narrowing. We recommend brachiocephalic-subclavian arteriography only in patients with abnormal noninvasive screening for subclavian stenosis, not routinely.     

Off-pump coronary artery bypass surgery

Off-pump coronary artery bypass surgery has been adopted enthusiastically worldwide. However, despite more than 6 years' experience and refinement, many surgeons use it only sporadically and some hardly at all. This reluctance persists despite support for the procedure because of the lack of properly designed risk models and/or randomized studies. Although it has not been overwhelmingly shown that off-pump surgery is superior to the conventional on-pump procedure, the technique has its place in our specialty. It has been shown to be better for noncritical end points in selected patients in the hands of selected surgeons. That there are differences in surgical skill among surgeons is something we all know but rarely discuss in public. Until now, disparities in skill have been most salient with uncommon and extraordinarily challenging operations. Perhaps the off-pump procedure should be regarded as the "challenging" aspect of coronary artery bypass surgery, and self-restraint may need to remain in force if we are to continue to achieve the highest level of clinical excellence.     

Time course and prognostic implications of QT interval in patients with coronary artery disease undergoing coronary bypass surgery

Course and Prognostic Implication of QT After CABG . Introduction: The aim of the present study was to determine the prognostic implication of preoperative QT interval in relation to overall death and sudden cardiac death after coronary bypass surgery and to investigate the course of QT interval after surgery. Methods and Results: Of 812 consecutive patients undergoing isolated off‐pump coronary surgery, 656 were retrospectively analyzed after excluding the 48 patients who were taking QT prolonging drugs and the 108 patients who had any of the following electrocardiographic findings: atrial fibrillation, pacemaker, QRS of >120 milliseconds, bundle branch block. QT intervals were corrected for heart rate (QTc) using Bazett's formula. Prolonged QTc was defined as QTc of ≥450 milliseconds in men (n = 144) and ≥470 milliseconds in women (n = 36). The 5‐year cumulative rate of sudden cardiac death in patients with prolonged QTc was 25% against 4% for those with normal QTc (P = 0.01). The risk‐adjusted hazard ratio (95% confidence interval) for the association between preoperative QTc and overall death was 1.47 (1.21–1.74) per 1‐SD increase in QTc; and 2.38 (1.50–3.45) for prolonged versus normal QT. For sudden cardiac death, the respective ratios were 1.63 (1.32–2.25) per 1‐SD increase in QTc; and 3.32 (2.14–4.23). QTc interval did not change during the first year after surgery, but increased significantly during the subsequent years. Patients with prolonged QTc before surgery had consistently longer QTc even after revascularization than those with normal QTc. Conclusion: Preoperative QT interval was an independent predictor of overall death and sudden cardiac death after isolated coronary bypass surgery. (J Cardiovasc Electrophysiol, Vol. 23, pp. 645–649, June 2012)     

120例回收式自体输血在非停跳冠状动脉旁路移植术中的临床应用分析

目的：观察回收式自体输血在非停跳冠状动脉旁路移植术（OPCABG）中应用的临床效果。方法：我院择期行OPCABG ASAⅡ～Ⅲ,心功能Ⅱ～Ⅲ（NYHA）,且自愿接受自体血回输患者120例。监测患者术前及术中HR、平均动脉压（MAP）、氧分压（PaO2）、血细胞比容（Hct）、血小板计数（PLT）、活化凝血时间（ACT）及凝血酶原时间（PT）等的变化。同时分别于术前和回输后采外周静脉血2 mL,自体血回输前,即刻采集同体积洗涤红细胞涂片,显微镜下观察红细胞形态,且留取回输前即刻至回输后3h内的尿样行尿血红蛋白定性检测。结果：自体血回输前MAP较术前下降,HR略有升高,回输后二者已基本恢复到术前水平;而Hb,Hct和PLT均较术前明显降低,PT延长;而自体血回输后,HB、HCT显著回升,机体低血红蛋白状态得到改善;自体血回输后,PLT和PT在正常范围内,较回输前无明显变化;ACT值略有下降,但同术前相比,差异无统计学意义（P〉0.05）。洗涤红细胞涂片可见红细胞棘状变形,约4～6个/高倍视野,占总数的15%～25%,偶见红细胞碎片,而自体血回输后涂片,红细胞形态大致正常,少见变形红细胞,未见红细胞碎片。尿血红蛋白定性检测结果：血红蛋白尿弱阳性3例,血红蛋白尿比例为2.5%。结论：回收式自体输血可节约血源,纠正失血及贫血,维持血流动力学稳定,对凝血功能无明显影响,在非体外循环冠状动脉旁路移植术中,回收式自体输血作为一种血液保护措施,可应用于临床。     

Awake off- pump coronary artery bypass surgery in 25 patients

Objectives To test the feasibility of the use of high thoracic epidural anesthesia as a sole anesthetic in patients undergoing off pump coronary artery bypass surgery, avoiding general anesthesia. Methods Between October 2002 to April 2003, twenty five cases underwent beating heart coronary artery revascularization without endotracheal general anesthesia, using high thoracic epidural anesthesia and analgesia. All the patients underwent epidural catheterization on the evening before the surgery. Resuits The patients in all received 71 grafts (single n= 11, double n = 5, triple n = 6, quadruple n =3). Six patients underwent repeat coronary artery bypass. Except one was converted to general anesthesia and cardiopulmonary bypass, the other patients underwent off- pump coronary artery bypass graft surgery, 2 patients underwent grafting via left thoracotomy (MIDCAB) and the rest through mid sternotomy. There was no mortality. Mean length of stay in the intensive care unit was 16 . 2 ( 4.2 hours and hospital was 3.0(1.2 days. Conclusions Our experience confirms the feasibility of performing muhiple coronary artery bypasses in conscious patients without endotracheal general anesthesia.     

Primary angioplasty in patients following coronary artery bypass surgery

Objectives : We aimed to study the trends in management and outcome of post CABG patients presenting with acute MI. Background: Primary angioplasty is the treatment of choice in patients with acute myocardial infarction. Saphenous vein grafts used for CABG are large‐diameter conduits that tend to accumulate a large mass of thrombus when they are the culprit artery for acute myocardial infarction (MI). We hypothesized that performing PCI in these patients is more complex and possibly results in worse outcome compared to non‐CABG patients. Methods : Data for patients with STEMI was obtained from five acute coronary syndromes Israeli biennial Surveys (ACSIS) during 2000–2008. Baseline characteristics, management and outcome of post‐CABG patients were compared to non‐post CABG patients during 2006–2008 surveys. Results : A total of 9,781 patients were included. About 1,002 (10.2%) were post‐CABG. Reperfusion therapy for post‐CABG patients (34–48%) was consistently lower compared to non‐CABG patients (57–65%). Angiographic outcome in patients with STEMI who underwent primary PCI (17 post‐CABG, mean age 66.6 ± 9.1 and 821 non‐CABG, age 60.1 ± 12.9) was successful (TIMI flow 3) in 86 and 88%, respectively. Thirty‐day mortality was 5.9 and 5.1% (P = 0.89) and MACE rates were 17.6 and 12.5%, respectively (P = 0.54). Conclusions : Use of primary PCI in post‐CABG patients was lower than in non‐CABG patients but increased steadily and to a similar extent in both groups. Angiographic and clinical outcome was similar despite assumingly larger thrombus burden in post CABG patients. Therefore, primary angioplasty is appropriate also in post‐CABG patients presenting with STEMI. © 2011 Wiley‐Liss, Inc.     

Caregiver burden and outcomes of caregiving of spouses of patients who undergo coronary artery bypass graft surgery

BACKGROUND: Patients who undergo coronary artery bypass graft surgery often rely on spouses for care during recovery. Although often meaningful, caregiving may be stressful and affect spouses' ability to provide care to the patient. OBJECTIVES: The purpose of this study was to compare burden and caregiving outcomes across three groups of spouses. Spouse groups varied by the interval of time between surgery and follow-up, which may have been 3, 6, or 12 months. METHODS: This cross-sectional comparative study recruited a convenience sample of 166 spouses on the basis of a power analysis. A total of 166 spouses completed caregiver surveys on burden and other caregiving outcomes. RESULTS: Total, objective, and subjective burden levels were low to moderate. Although no burden differences were found between groups, men had higher total burden but more positive caregiving outcomes. Future outlook and social activities were less positive in the 6-month group. Burden levels were not lower, nor were caregiving outcomes higher, in the 12-month group, suggesting a steady caregiving demand across the first year after coronary artery bypass graft surgery. CONCLUSION: Longitudinal investigations are needed to understand burden and caregiving outcomes over time and the impact of burden on spousal and patient recovery outcomes.     

心脏直视手术前颈动脉支架术的初步探讨

目的 评估心脏疾病合并严重颈动脉狭窄患者于心脏直视手术前行颈动脉支架术预防围手术期缺血性卒中的有效性和安全性.方法 前瞻性队列研究,对心脏疾病合并严重颈动脉狭窄患者于心脏直视手术前行颈动脉支架术,评估颈动脉支架术至心脏直视术后30 d的终点事件(卒中、心肌梗死和死亡).结果 自2005年1月至2007年12月,本研究共连续入选42例患者.颈动脉支架技术成功率100%.远端栓塞防护装置使用率为97.6%(41/42).心脏直视手术包括:冠状动脉旁路移植术36例(85.7%),冠状动脉旁路移植术加瓣膜置换术5例(11.9%),瓣膜置换术1例(2.4%).自颈动脉支架术至心脏直视术后30 d的卒中率为2.4%(1/42),心肌梗死率为0%,死亡率为0%.结论 这一小样本前瞻性队列研究表明,心脏直视手术前行颈动脉支架术预防围手术期缺血性卒中安全有效,优于文献报告的分期颈动脉内膜剥脱术的结果,但由于本研究样本量小,需进一步研究验证.     

冠状动脉搭桥与冠脉介入治疗的比较

冠状动脉旁路移植术（CABG）和经皮冠状动脉介入术（PCI）是目前治疗冠状动脉狭窄的两种主要治疗方法。CABG是半个世纪以来治疗冠心病经典手段之一,近年来由于对桥血管的选择和保护、全动脉再血管化等的重视,其近远期治疗效果明显提高。随着介入技术的发展,这项技术以其微创、安全、易于被患者所接受等特点,适应证不断扩大。本文就近年来CABG和PCI在治疗冠心病方面的发展和优势作一综述。     

Effects of dexamethason on the early postoperative course after coronary artery bypass surgery

The effects of dexamethason (DM) on the postoperative course of coronary artery bypass have been investigated in a double blind study. Twenty patients receiving dexamethason 1 mg/kg body weight intravenously (IV) before cardiopulmonary bypass are compared with a control group of 20 patients receiving placebo. In the treated group core temperature remained normal (maximum 37.6 +/- 0.5 degrees C) while in the control group the patients regularly developed fever (39.0 +/- 0.7 degrees C; p less than 0.01). In the DM-treated group a significantly higher blood pressure, and a lower incidence of rhythm disorders were found. There was a marked difference in the fluid requirements between the 2 groups. Without DM the fluid balance was 2,300 cc positive at the end of the study, in the treatment group this excess was only 1,000 cc (p less than 0.001). Dexamethason treatment also led to higher urine output (130 cc/hr, vs. 85 cc/hr). Although the arterial oxygen tension was higher in the treated group, no patient developed respiratory insufficiency in the control group. The post-pump syndrome is re-evaluated and possible mechanisms are discussed.     

Conscious off-pump coronary artery bypass surgery

BACKGROUND: Cardiothoracic surgery has been previously performed successfully under thoracic epidural anesthesia alone. Between October 2001 and December 2003, we performed 123 conscious off-pump coronary artery bypass surgeries using epidural anesthesia as the sole anesthetic. This technique is an alternative to cardiothoracic surgery performed under general anesthesia. Certain modifications in the technique facilitate the process. METHODS AND RESULTS: There were 24 female patients and 99 male patients with mean age of 58.6 +/- 6.2 years; 12 patients underwent repeat coronary artery bypass surgery. All the patients underwent epidural catheterization on the evening before surgery. Out of the 123 patients scheduled for coronary artery bypass graft surgery, 120 underwent off-pump coronary artery bypass graft surgery successfully; 4 patients underwent off-pump surgery via left thoracotomy and the rest through mid sternotomy. These patients received 295 grafts in all (single graft in 26 patients, double in 42 patients, triple in 35 patients, and quadruple in 20 patients). Three patients required conversion to general anesthesia and one to cardiopulmonary bypass. There was no mortality in the group. CONCLUSIONS: Our experience suggests that by modifying the surgical techniques, we can accomplish conscious coronary artery bypass surgery.