Anastomotic pseudoaneurysm after aorto-coronary bypass grafting

A patient with a pseudoaneurysm at the site of the distal anastomosis of a saphenous vein coronary bypass graft is described. The aneurysm was resected. To our knowledge this is the first report of this complication after coronary bypass surgery.     

Ventricular arrhythmia before and after aorto-coronary bypass surgery

The influence of aorto-coronary bypass surgery (ACBS) on ventricular arrhythmia was examined in 57 patients. Six-hour Holter monitoring was done on the day prior to and 3 mth after ACBS. None of the patients were on any antiarrhythmic drugs during these recordings. Ventricular arrhythmia was classified into three groups: Group I (45 patients) had an average of < 10 premature ventricular contractions (PVCs) per hour, Group II (7 patients), 11–30 PVCs per hour and Group III (5 patients), > 30 PVCs per hour. There was no significant change in the number of patients in each group after ACBS. Complex PVCs were present in 8 patients preoperatively and in 9 patients after ACBS. The number of diseased vessels and the extent of left ventricular wall motion abnormality noted preoperatively, had no effect on ventricular arrhythmia following surgery. These data show that ACBS, when performed to relieve angina, does not have a significant effect on the prevalence of PVCs and does not prevent or reduce the occurrence of complex PVCs.     

Long-term clinical results after intervention using aorto-coronary bypass

The survival and symptoms of 294 consecutive patients discharged from the hospital after isolated coronary artery bypass grafting from 1970 to 1975 were evaluated 6 to 10 years after surgery. The actuarial 10 years expectancy of cardiac death as 10.0 +/- 2.4% the non fatal myocardial infarction one was 11.2 +/- 2.8; the yearly probability of severe ischemic event therefore was 2.1%. One year after surgery, 56% patients were free from angina, 31% improved and only 7% symptomatically unchanged. These percentages became 45%, 26% and 13% respectively at the end of the follow-up, thus showing a definite though slight deterioration. Clinical status one year after operation was predictive of further evolution: only 6.2% of the symptom-free patients developed severe ischemic events, as opposed to 20% of the highly symptomatic ones. The actuarially determined curve of recurrence of angina in the patients asymptomatic at the first control shows, after 2 years of steady state, a progressive upslope which reaches 40% by the 7th year and 90% at the 10th year of follow-up. Subgroup analysis indicated that long term prognosis is influenced by the presence of left main stenosis and by perioperative myocardial damage. Clinical results at one year are influenced by completeness of revascularization, graft patency and perioperative myocardial infarction. The tendency of symptoms to recur in patients who are free from angina one year after intervention, is similar in the various subgroups and is adversely influenced only by perioperative myocardial damage. These results show that coronary artery bypass grafting has a true clinical impact, although symptomatic improvement is somewhat temporary.     

Blood flow in the transplant after aorto-coronary bypass]

With the help of an electromagnetic flowmeter the authors measured the blood flow in the graft during aorto-coronary bypass procedures. The flow was measured in 74 patients with 88 bypass grafts, along them--in 43 grafts to the right coronary artery, in 31 grafts to the anterior interventricular artery, and in 14 cases of double aoroto-coronary bypass grafts. In 21 cases the flow was measured in the coronary artery graft after endarterectomy. The analysis has demonstrated that the flow in the graft depends on many factors, the leading among which is the severity of the coronary lesion, the state of its distal portion and of the cardiac muscle in the zone of the diseased coronary artery. A direct relationship was established between the degree of the narrowing of the proximal coronaries and the flow values in the graft connected with the artery in question. The greater the stenosis in the proximal portion of the coronary artery, the higher the blood flow in the bypass. The highest blood flow was registered in cases of complete coronary occlusions. Blood flow measurements in the bypass grafts during surgery help to determine the amount of blld supplied to the revascularized myocardium and, hence, to assess the direct efficacy of the aorto-coronary bypass procedures in the management of the ischaemic heart disease.     

Preliminary study on the resumption of work after aorto-coronary bypass

A questionnaire was sent 8 months to 3 years after aorto-coronary bypass to 98 patients who, before surgery, had had to abandon their professional activities because of ischaemic heart disease to assess the numbers who had returned to work: thirty six patients (37%) had not returned to work for medical or personal reasons; only one patient had been refused by his employee; sixty two patients (63%) had returned to work, 81% full-time and 19% with a different job. Only 19% had to stop working secondarily for medical reasons. The criteria thought initially to influence the chances of resumption of professional activity were analysed: factors not influencing the return to work were: type of work before operation (judged by the physical activity involved and the statute of salaried or independent worker), the severity of surgery (number of grafts and associated resection of aneurysm), a subjective assessment of physical condition after surgery (91% or patients not returning to work admitted to feeling well); uncontrollable factors influencing the return to work were: age of patient (average 51,7 years for those returning to work, compared to 55,1 years for the others), previous history of myocardial infarction (2,5 times more common in those not returning to work); finally, controllable factors influencing return to work were: the duration of unemployment before surgery (3,3 months for those returning full-time, compared to 16,4 months for those not returning to work); the period between surgery and resumption of activity which averaged 5 months and should not exceed 6 months. Three factors seemed to be particularly important: apart from the shortest possible period of unemployment before surgery, early physical reeducation after surgery based on chest physiotherapy and readaptation to physical activity and a psychological preparation for the return to work which should be started even before surgery.     

Indication for early aorto-coronary bypass surgery after successful intracoronary lysis

Intracoronary lysis (ICL) was carried out in 108 patients with acute coronary artery thrombosis. In 79 subjects, recanalization of the occluded vessel was achieved, while 29 patients were unresponsive to the method. Thirty patients required early aorto-coronary bypass (ACB) surgery after successful ICL, while 49 patients with successful lysis were treated medically as well as the 29 patients with unsuccessful lysis. Mortality was 20% among the patients unresponsive to ICL, 12% among the 49 patients with successful lysis treated on a medical regimen thereafter, and 3.3% among the 30 patients undergoing early surgery after successful lysis. Early aorto-coronary surgery, however, was felt to be indicated only when the myocardium supplied by the occluded vessel was still viable. Beside LV angiography and ECG studies, intracoronary Thallium-scintigraphy was most helpful in assessing the viability of the heart muscle.     

Miliary tuberculosis with atypical radiographic findings after aorto-coronary bypass surgery]

Dry cough and exertional dyspnea developed in a 78-year-old man after aorto-coronary bypass surgery for angina pectoris. Chest X-ray films showed small nodular shadows in the upper and middle fields of both lungs. The patient's condition was exacerbated despite treatment with antibiotics. Chest high-resolution computed tomography disclosed small nodular and reticulo-linear shadows predominantly in the interlobular septa and bronchovascular bundles. Transbronchial lung biopsy specimens revealed micro-granulomas with necrosis, suggesting miliary tuberculosis. Antituberculosis drugs were started and the patient's symptoms and radiographic findings gradually resolved. Cases of cellular immunosuppression have beer reported in patients following open-heart surgery that utilized antifical heart and lung apparatus. Such procedures, together with hemodialysis, deserve consideration as potential risk factors for miliary tuberculosis.     

Valve replacement and aorto-coronary bypass]

Combined surgery on the valves and on the coronary arteries by bypass grafts has been carried out on 27 consecutive patients (1970 to 1976) and involved 18 aortic valve replacements, 8 mitral valve replacements, and one double mitro-aortic replacement; the mean duration of extra-corporeal circulation (145 mn) was significantly higher than that for valve replacements alone carried out during the same period (p less than 0.01). The five deaths occurring in hospital (18.5%) all occurred in the aortic valve group, and were amongst the first 15 cases operated on (1970 to 1974). The 4 post-mortem studies carried out showed similar findings, namely myocardial infarction and significant coronary lesions which had not been bypassed. Two secondary deaths due to infective complications occurred in the first six months. The 17 patients who were followed up after surgery and had a mean follow-up period of 24 months, were all substantially improved by comparison with their pre-operative state, despite certain complications affecting either the valves (1 requiring re-operation) or the coronary arteries (3 infarcts). The indications for coronary arteriography, which are related to the indications for surgery, are being enlarged so that they will include the majority of patients operated on excluding those of more than 65 to 70 years of age and also those aged less than 40 years who have no risk factors for atherosclerosis and no clinical or electrocardiographic signs suggesting a coronary lesion. A study of the operative risk factors has shown the importance of unsuspected coronary lesions, and would appear to indicate correction of all valvular and coronary lesions seen at the time of operation.     

Moderate aortic stenosis and aorto-coronary bypass

The presence of aortic stenosis in a patient facing surgical coronary revascularisation is a common situation. A tight aortic stenosis justifies combining aortic valvular replacement with the anticipated bypass. The discovery of a "moderate" aortic stenosis before coronary surgery poses a much more difficult problem. Moderate stenosis equates to aortic area values >0.6 cm2/m2 body area and <1.2 cm2/m2. An estimation of the progression of the stenosis following coronary surgery is fundamental to making the best possible decision but remains very difficult for a given individual. The factors to be taken into account are the aetiology of the stenosis, its severity, the valvular anatomy (calcification), associated coronary artery disease, the age of the patient and the progression of stenosis from one echography to the next. For each patient the risk/benefit ratio of the strategy must therefore be evaluated as much as possible (double procedure at once, or bypass followed by surveillance of the aortic stenosis). In order to do this it is necessary to consider, apart from the stenosis progression factors, the patient's life expectancy and point of view, as well as of course the operative risk (LV function, comorbidity...). Day to day experience shows that the degree of the stenosis is often under-estimated in patients facing coronary surgery, owing to a simple measurement of the gradient. Complete and accurate investigation of the aortic stenosis with Doppler often allows a definitive decision on the most suitable therapeutic approach.     

Fate of coronary collateral circulation after aorto-coronary saphenous vein bypass grafts.

The pre- and postoperative patterns of coronary artery collateral circulation have been studied in 34 patients who had saphenous vein bypass grafting. When the graft remained patent homocoronary collaterals could not be visualized after operation, but new intercoronary anastomoses frequently developed to other diseased arteries. When the graft and the bypassed artery were both obstructed there was a high incidence (5 out of 11) of myocardial infarction despite good preoperative collaterals.     

Emergency aorto-coronary bypass surgery after percutaneous transluminal coronary recanalization--its indication and results

Percutaneous transluminal coronary recanalization (PTCR) was carried out in 201 patients with acute myocardial infarction. Fifteen patients required emergency aorto-coronary bypass grafting (ACBG) subsequent to PTCR; in one immediately following unsuccessful thrombolysis and the remaining 14 patients within 10 days after initial successful recanalization because of reinfarction. One patient died of multiorgan failure postoperatively. Excluding one patient, all patients had left main trunk disease (LMTD) and/or 3 vessel disease (3VD), with residual stenosis at the site of recanalization of greater than 99% with filling delay. Nonsurviving without surgery and medically managed patients on whom repeated angiography was carried out also analysed, in an effort to establish angiographic indications for supplementary surgical revascularization. Patients having extensive coronary artery disease such as LMTD and/or 3VD, emergency ACBG should be performed immediately following PTCR, if the remaining causative stenosis is greater than 99% with filing delay.     

The aorto-coronary bypass in the elderly patient

In the FRG one person every ten is more than 70-years old; the average life expectancy, often underestimated, is about 11 years for the 70-years old and 6 years for 80-years old. The modern approach to coronary disease has broadened the indications for coronary artery bypass grafting in the elderly. The present report, studying 152 patients more than 70-years old, suggests the usefulness of a myocardial revascularization in the elderly; it remains to define the relative contraindications (renal failure, high LVEDP, valve replacement). However, the symptomatic improvement we could achieve (95.45%) seems to be a good result, considering the low CABG-related postoperative lethality (1.9%). The trend of our results regardless of 5 years survival is also encouraging (85.1%).     

Intraoperative echocardiographic visualization of coronary arteries, before and after aorto-coronary bypass grafting

Summary While angiography remains the standard evaluation method for the visualisation of coronary artery anatomy and morphology, the angiographic findings in patients referred for surgical treatment of coronary artery disease (CAD) often do not totally answer questions related to surgical management. We therefore explored a high-frequency ultrasonic technique that allows the surgeon to localize coronary artery lesions not demonstrated angiographically, such as the distribution of coronary artery calcification in myocardial vessels buried in fat or obscured by epicardial scarring frequently observed in patients who had previously been operated upon.Coronary arteries of 81 patients were investigated intraoperatively. Stenotic arteriosclerotic or fibrotic lesions of the arterial wall could be easily seen. This technique provides additional information to preoperative angiograms, especially in locating major coronary arteries that lie intramyocardially, or those deeply buried in fat.Intraoperative coronary artery dilatation procedures could be followed and the effects determined by measuring pre- and postoperative diameters.     

A case of aorto-coronary bypass in Jehovah's Witness

An aorto-coronary bypass grafting was performed in a 50 year-old man, a Jehovah's Witness, suffering from effort angina pectoris. Preoperatively, he was underwent PTCA for LAD occlusion, which failed. Single aorto-coronary bypass grafting using IMA was performed under the extracorporeal circulation primed with Ringer's Lactate and albumin. Moderate hypothermia with core temperature of 31.5 degrees C was used, and minimal level of the hematocrit was 18% during the perfusion. At the start of the operation, 800 ml of blood were withdrawn from the jugular vein to the blood bag which connected to a peripheral venous line uninterruptedly. During the operation, the autologous blood was continuously transfused very slowly and most of the autologous blood was transfused after the termination of extracorporeal circulation. The blood in the extracorporeal circuit was hemoconcentrated with ECUM (extracorporeal ultrafiltration method) from hematocrit level 22% to 35% and transfused. The postoperative course was uneventful. At the time of discharge from hospital on the 42nd postoperative day the hemoglobin level was 13.1 g/dl and hematocrit level was 42%.     

Survival at 5 to 10 years after aorto-coronary bypass operations in 1041 consecutive patients

To evaluate longterm survival, 1041 consecutive patients withaorto-coronary bypass operations were followed for a mean of7.5 years (range 5 to 14.5). The peri-operative mortality was12 (1.2%). Of the 131 late deaths, 97 (74%) were cardiac inorigin. The survival probability at 5 years was 92 ±2%and at 10 years 79 ±4%. Figures for a matched generalDutch population are 94% and 87%, respectively. Stepwise multivariate analysis revealed an association betweendeath rate and impaired left ventricular function (rate ratioimpaired function versus normal: 1.82, P =0.0007) and extentof vascular disease (rate ratio 3 vessel-versus 1 vessel disease:1.80, P = 0.01) while no relation was found with sex or ageat operation. Surgery seems to provide a good probability of survival, althoughin patients with extensive vascular involvement and/or a decreasedleft ventricular function at the time of operation, the longtermoutlook is less favourable than for those without these characteristics.