MIDCAB for redo patients using the LITA-RA composite graft

Redo coronary artery bypass grafting (CABG) is associated with higher mortality, low-output syndrome, perioperative myocardial infarction than primary CABG. Minimally invasive direct coronary artery bypass grafting (MIDCAB) technique avoids the manipulation of old graft and injury of the adhesive heart in redo operation. We performed the MIDCAB procedure for 2 redo cases using the left internal thoracic artery (LITA)-radial artery (RA) composite graft. The LITA-RA composite graft was anastomosed to the left anterior descending branch (LAD) through small left anterior thoracotomy without cardiopulmonary bypass. Postoperative coronary artery graphy shows the widely patent of new graft. The MIDCAB procedure using the LITA-RA composite graft is safe and useful to regulate the bypass graft length and avoid the widely harvest of LITA in redo operation.     

体外循环与非体外循环下冠脉搭桥术患者术中血液动力学的比较

目的比较体外循环(CPB)与非CPB下冠脉搭桥术患者术中血液动力学的变化。方法同期行CPB下冠状动脉搭桥术(CABG)与非CPB下冠状动脉搭桥术(OPCAB)患者各70例,分别为CABG组和OPCAB组,分别在麻醉诱导后手术开始前(术前)和术毕用Swan-Ganz导管监测血液动力学指标。结果与术前比较,两组术毕心率(HR)、平均动脉压(MAP)、肺动脉平均压(PAMP)、肺毛细血管嵌压(PAWP)、中心静脉压(CVP)及左室作功指数(LVSWI)差异无统计学意义(P>0.05),心输出量(CO)、心脏指数(CI)均升高;OPCAB组术毕心搏指数(SVI)升高,体循环阻力指数(SVRI)、肺循环阻力指数(PVRI)降低(P<0.05),CABG组术毕SVI、SVRI、PVRI差异无统计学意义(P>0.05);与CABG组比较,OPCAB组术毕SVRI、PVRI降低(P<0.05)。结论两组患者术后心功能均得到了改善,OPCAB 组在改善心功能、降低体、肺循环阻力方面,优于CABG组。     

非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例

目的总结非体外循环下采用双侧乳内动脉Y型桥进行完全心肌血运重建的冠状动脉旁路移植手术125例的近期疗效。方法2002年10月至2005年12月,完成125例不停跳非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植手术,术中采用带蒂半骨骼化的方法分别取材左、右侧的乳内动脉,将左、右乳内动脉端侧吻合成Y型桥;在非体外循环下,应用序贯吻合的方法进行冠状动脉搭桥手术。结果全组125例患者共搭桥413支,平均搭桥支数3．3支／例。术中流量测定桥血管均通畅。全组患者无围手术期死亡。结论非体外循环下双乳内动脉Y型桥的冠状动脉旁路移植手术是安全、有效的方法,可以实现全动脉化的完全心肌血运重建,又避免手术中对升主动脉的操作,近期效果满意。     

Reoperative Coronary Artery Bypass Grafting Via a Left Thoracotomy and a Small Laparotomy Without Cardiopulmonary Bypass: Report of a Case

A 66-year-old woman with aortic stenosis underwent an aortic root replacement with a composite graft and coronary artery reconstruction 2 years before presentation. On coronary angiography performed 2 years after operation, saphenous vein graft (SVG) to right coronary artery and SVG to first diagonal branch had both become totally occluded. SVG to left anterior descending artery showed 75% stenosis on the heel side of the distal anastomosis. The patient underwent a second coronary artery bypass via a left thoracotomy (the left internal thoracic artery was anastomosed to the first diagonal branch by interposing it with the left radial artery) and a small laparotomy (the right gastroepiploic artery was anastomosed to the right coronary artery) without a cardiopulmonary bypass. This approach is preferable to avoiding both a resternotomy and cardiopulmonary bypass in patients requiring repeat surgery. Received: September 29, 2000 / Accepted: May 15, 2001     

Redo coronary artery bypass grafting using the patent left internal thoracic artery graft as an in flow with composite internal thoracic artery Y grafting; report of a case

In redo coronary artery bypass grafting (CABG), graft selection and revascularization methods are major problems. We experienced a redo-CABG with occluded previous vein grafts. These grafts were to the circumflex artery and right coronary artery. We conducted operation using cardiopulmonary bypass. We at this operation, chose right internal thoracic artery (RITA) as a conduit and anastomosed it to the side of functioning left internal thoracic artery (LITA) graft, and then diogonal branch, posterolateral branch, and atrioventricular branch were revascularized with the RITA. Post operative course was uneventful. Internal thoracic artery (ITA) is superior to vein graft and other arterial graft as to long term patency. We believe composite Y graft with the use of bilateral ITA can be one of the revascularization strategy in redo CABG.     

Coronary artery bypass grafting with the right gastroepiploic artery

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.     

Initial experience with MIDCAB grafting using the gastroepiploic artery.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting with the gastroepiploic artery can be used in primary operations and reoperations to revascularize the inferior or anterior surface of the heart. METHODS: Patients who had symptomatic coronary artery disease limited to a single coronary distribution were selected. Coronary targets were grafted with the pedicled gastroepiploic artery through a small midline epigastric incision. Patients were followed with scheduled outpatient clinic visits, Doppler examination, and selective recatheterization. RESULTS: Between May 1995 and November 1997, 74 patients underwent gastroepiploic artery minimally invasive direct coronary artery bypass grafting; 33 (45%) had a primary operation and 41 (55%), a reoperation. Grafting was performed to the distal right coronary artery (n = 38), the posterior descending artery (n = 28), or the distal left anterior descending coronary artery (n = 8). There were six deaths (8%) within 30 days after operation. Twenty patients (28%) underwent recatheterization; there were two graft occlusions, two graft stenoses, and five anastomotic stenoses. Of 60 patients seen 2 or more weeks after operation, 53 (88%) had resolution of anginal symptoms at a mean follow-up of 10.9 months (range, 0 to 30 months). CONCLUSIONS: Inferior minimally invasive direct coronary artery bypass grafting with the gastroepiploic artery avoids the risks of repeat sternotomy, aortic manipulation, and cardiopulmonary bypass. Patency rates, however, were lower than expected, and there is significant morbidity and mortality associated with high-risk patients undergoing the procedure. Continued follow-up is essential to evaluate long-term graft patency and patient survival.     

Two cases of off-pump coronary artery bypass grafting combined with abdominal aortic aneurysm repair.

Two cases of coronary artery disease coexisting with abdominal aortic aneurysm were treated with off-pump coronary artery bypass grafting combined with repair of the aneurysm. The first patient was a 67-year-old man exhibiting a large pulsating abdominal mass. Abdominal computed tomography demonstrated a 9-cm aneurysm and coronary angiogram revealed a 90% stenosis of the obtuse marginal branch for which percutaneous transluminal angioplasty could not be performed. He underwent simultaneous single coronary artery bypass grafting without cardiopulmonary bypass, and bifurcated graft replacement. The second patient was a 71-year-old man who had acute myocardial infarction, and one month later underwent coronary angiogram which revealed three vessel disease in the coronary artery. Computed tomography revealed a 4-cm aneurysm, and angiography showed a 90% stenosis of the left renal artery. He underwent a single stage operation that involved three coronary artery bypass grafting without cardiopulmonary bypass, straight graft replacement, and reconstruction of the left renal artery using the saphenous vein graft. The postoperative course was uneventful in both cases. We currently recommend a single stage operation involving off-pump coronary artery bypass grafting.     

Reoperative coronary artery bypass grafting using a minimally invasive direct coronary artery bypass procedure

OBJECTIVE: Reoperative coronary artery bypass grafting with cardiopulmonary bypass tends to cause a higher mortality and morbidity than the primary operation. The purpose of this study was to discuss the effectiveness and safety of a minimally invasive coronary artery bypass procedure for patients who had previously undergone coronary artery bypass surgery. METHODS: We performed redo single coronary artery bypass grafting to the left anterior descending coronary artery in 9 patients and to the right coronary artery in 3 patients using minimally invasive cardiac surgery. The graft to the left anterior descending coronary artery was taken from the left internal thoracic artery in 5 patients, the right gastroepiploic artery in 3 patients, and from the saphenous vein in the other 1 patient. The graft to the right coronary artery was from the right gastroepiploic artery in all 3 patients. RESULTS: All grafts were patent. There was no major postoperative complication and no surgical or hospital death except one late death. CONCLUSIONS: In selected patients, we could safely and completely perform coronary artery bypass re-grafting to the left descending coronary artery or right coronary artery using a minimally invasive operation.     

Risk factors for nosocomial pneumonia after coronary artery bypass graft operations.

We attempted to determine risk factors for nosocomial pneumonia in patients undergoing a coronary artery bypass graft operation. We reviewed the microbiology and medical records for any patient with a sputum culture who had undergone a coronary artery bypass graft operation in 1988 to identify patients with pneumonia according to a standard clinical definition. We found 19 cases of pneumonia through our initial review; complete medical records were found on 15 cases. Gram-negative bacilli predominated as the most common etiologic agent causing pneumonia in this cohort. There were no clusters noted. Mortality was 26.6%. Pneumonia occurred approximately 4 days after the operation. Thirty-six controls were randomly selected from patients undergoing coronary artery bypass graft operations in 1988. Logistic regression analysis revealed that a history of chronic obstructive lung disease, duration of more than 2 days of mechanical ventilation after operation but before diagnosis of pneumonia, and receipt of gastric acid inhibitors (antacids or H2-blockers) were independent risk factors for nosocomial pneumonia. Only the last risk factor was amenable to intervention at the time of operation.     

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was frist replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.     

A combined operation of coronary revascularization, abdominal aortic aneurysmectomy and femoro-popliteal bypass]

A 71-year-old male with abdominal aortic aneurysm, coronary artery disease and obstructive peripheral arteriosclerosis successfully underwent a combined operation of coronary artery bypass grafting (CABG), replacement of abdominal aortic aneurysm and femoro-popliteal bypass. In this combined operation, the right gastroepiploic artery (GEA) is suitable as a bypass graft, because a laparotomy is required for abdominal aortic aneurysmectomy. And the usage of arterial grafts such as GEA and the left internal thoracic artery (LITA) is reasonable in terms of avoiding hazardous proximal anastomosis and reducing the operating time.     

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm.

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was first replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.     

Urgent coronary artery bypass graft operation of a patient with acute anterior myocardial infarction,congenital right coronary artery to main pulmonary artery fistula and left hilar hamartoma of the lung

BACKGROUND: Coronary artery fistulas are rare congenital or acquired coronary artery anomalies that can originate from any of the three major coronary arteries and drain into all the cardiac chambers and great vessels. METHODS (CASE REPORT): A 67-year-old male patient administered to the emergency department with a severe unstable angina pectoris. Patient underwent a three-vessel coronary artery bypass graft surgery, liga-clip occlusion of coronary artery to pulmonary artery fistula and a direct diagnostic punch biopsy from the left hilar mass lesion. RESULTS: No complications were encountered postoperatively. The patient was discharged on postoperative day eleven with a referral to the thoracic surgery department for further treatment of his lung tumor. CONCLUSIONS: In this report we present successful combination of an urgent coronary artery bypass graft operation in acute anterior myocardial infarction status with concomitant pathologies of congenital right coronary artery to main pulmonary artery fistula and left hilar mass lesion of the lung.     

True aneurysm of the saphenous vein graft stump associated with CABG in a cardiac transplant patient.

Aneurysm of a saphenous vein graft after coronary artery bypass requires surgical resection because of its potential for rupture. This report describes a case of aneurysm formation in a 55-year-old man who underwent coronary artery bypass operation in 1977 and orthotopic heart transplantation 7 years later. A proximal vein graft remnant that had been ligated at the time of transplantation developed into a 5-cm aneurysm. In patients who have undergone previous coronary artery bypass operation, we recommend that the entire vein graft stump be excised and oversewn at the aortosaphenous anastomosis at the time of transplantation.     

非体外循环双乳内动脉序贯旁路移植加选择性心中静脉动脉化手术的疗效分析

目的评价非体外循环双乳内动脉序贯旁路移植加选择性心中静脉动脉化（CVBG）手术的临床疗效。方法回顾性分析2004年3月至2010年8月首都医科大学附属北京安贞医院38例有弥漫性右冠状动脉狭窄患者行手术治疗的临床资料。按手术方式不同将其分为两组,CVBG组：17例,男11例,女6例;年龄46.1±6.2岁;行非体外循环双乳内动脉序贯旁路移植加选择性心中静脉动脉化。对照组：21例,男14例,女7例;年龄45.9±5.7岁;仅行双乳内动脉序贯旁路移植,但对右冠状动脉系统未做处理。术中采用血流量仪测量移植血管的血流量,并对两组移植血管支数、气管内插管时间、住院时间、主要并发症发生情况、超声心动图指标、心肌核素扫描和冠状动脉造影检查结果等进行比较。结果围术期两组患者均无死亡,均无脑部、胸骨和纵隔感染等并发症发生。CVBG组移植血管支数与对照组比较差异有统计学意义（3.3±1.1支vs.2.2±1.6支,P〈0.05）。CVBG组乳内动脉主干（81.5±32.7ml/min vs.76.8±28.4ml/min）、左乳内动脉主干（32.5±18.8ml/min vs.28.1±16.7ml/min）和右乳内动脉主干血流量（39.6±19.0ml/min vs.35.9±18.3ml/min）与对照组比较差异无统计学意义（P〉0.05）。随访38例,随访率100%,随访时间3～55个月（37.4±9.8个月）。CVBG组所有患者均未出现心绞痛,心电图示：下壁心肌缺血明显改善;对照组术后有8例患者出现心绞痛,心电图示：有下壁心肌缺血,ST-T改变;两组间差异有统计学意义（P〈0.05）。两组患者术后3个月心功能较术前明显改善。心肌核素扫描显示：CVBG组患者下壁心肌血液供应明显改善;冠状动脉造影证实动脉化后的冠状静脉内有血流通过。结论在非体外循环下行双乳内动脉序贯旁路移植加选择性心中静脉动脉化是可行的,术后患者心功能和生活质量均得到改善,为弥漫性右冠状动脉狭窄患者提供了新的外科治疗方法。     

On-line intraoperative quantitation of regional myocardial perfusion during coronary artery bypass graft operations with myocardial contrast two-dimensional echocardiography.

We hypothesized that the success of coronary artery bypass graft operations could be assessed by means of on-line quantitative myocardial contrast echocardiography. Accordingly, myocardial contrast echocardiography was performed at baseline and after each placement of venous graft in 21 patients undergoing coronary artery bypass graft operations. Time-intensity plots were generated on-line with the use of a dedicated computer system, and areas under the curve were assessed for each injection. Successful on-line quantitation of myocardial contrast echocardiography data was performed in 17 patients; this allowed comparison before and after coronary artery bypass graft operations for 21 grafts, with agreement between expert visual analysis and quantitative data in 91% of these cases. Three distinct perfusion patterns were noted on myocardial contrast echocardiography: (1) reduced contrast effect before coronary artery bypass graft operations with improvement after coronary artery bypass graft operations (n = 11); (2) adequate contrast effect before coronary artery bypass graft operations with no change after coronary artery bypass graft operations (n = 9) (for patients in group 2, the mean percentage of coronary stenosis was less than the mean for patients in group 1-67% +/- 25% vs. 88% +/- 20%, p = 0.05); and (3) no contrast effect either before or after coronary artery bypass graft operations in one patient with previous infarction. One third of the time (34 of 95 injections), on-line quantitation was unsuccessful. Failure was related three times more often to problems associated with myocardial contrast echocardiography, such as attenuation and inadequate quality of bubbles, than to computer failure. Despite its limitations, on-line quantitative myocardial contrast echocardiography is feasible in patients undergoing coronary artery bypass graft operations and provides important objective information regarding the success of revascularization.     

Coronary artery surgery is associated with different forms of atherogenic lipoprotein modifications

BACKGROUND: Increasing evidence shows that thrombogenicity and atherogenicity of lipoproteins are related to modifications involving oxidative, enzymatic, or physical alterations of these molecules. Findings on lipid peroxidation associated with cardiopulmonary bypass are conflicting, and the possible other forms of atherogenic lipid modification are unknown. The various forms of lipoprotein modifications including lipid peroxidation, desialylation, and leukocytic elastase activity after coronary artery bypass graft operations are examined. METHODS: In patients undergoing coronary artery bypass graft operations, plasma total lipid hydroperoxides (n = 102), plasma leukocytic elastase activity (n = 125), free radical formation (n = 30), low-density lipoprotein oxidation, and sialic acid content before operation and at 2, 24, 48, and 72 hours after cardiopulmonary bypass and 3 months after operation were measured. RESULTS: Preoperative plasma lipid peroxide concentration (2.2 micromol/L) increased after cardiopulmonary bypass (peak, 7.5 micromol/L; p<0.001) and remained significantly elevated at 3 months after surgery (4.2 micromol/L; p<0.01). There was a significant correlation between increased free radical generation and lipid peroxide levels in blood at all postoperative intervals. Low-density lipoprotein separated from plasma samples showed increased oxidation 48 hours after bypass. Sialic acid content of low-density lipoprotein was significantly reduced 48 hours after bypass. Plasma elastase activity increased significantly at all postoperative intervals. CONCLUSIONS: Coronary artery bypass graft operation is associated with generation of sustained blood levels of modified lipoproteins. These thrombogenic and atherogenic particles may play an important role in hemostatic and arteriosclerotic complications of coronary artery bypass graft operations.     

A comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients on hemodialysis

The hospital records of 22 patients on hemodialysis undergoing coronary artery bypass grafting, and 19 others undergoing percutaneous transluminal coronary angioplasty were reviewed to compare the outcomes of these procedures in this population. Evidence of previous myocardial infarction or triple vessel or left main coronary artery disease was more common in patients undergoing coronary artery bypass graft than those undergoing percutaneous transluminal coronary angioplasty. Perioperative mortality and complication rates following coronary artery bypass graft (4.5% and 41%, respectively) were similar to those following percutaneous transluminal coronary angioplasty (5.3% and 42%). Cardiac event-free rates at 18 months by life-table analysis following coronary artery bypass graft and percutaneous transluminal coronary angioplasty were 87±16% and 40±14%, respectively. Survival at 18 months were 67±17% following coronary artery bypass graft and 69±14% following percutaneous transluminal coronary angioplasty. Cardiac events were observed to occur in three patients undergoing coronary artery bypass graft at a median of 10 months, and in nine patients following percutaneous transluminal coronary angioplasty at a median of 6 months. One patient required percutaneous transluminal coronary angioplasty after the initial coronary artery bypass graft. Seven patients required repeat percutaneous transluminal coronary angioplasty, and two patients underwent coronary artery bypass graft after initial percutaneous transluminal coronary angioplasty. Although these conclusions are limited by the retrospective nature of the study, it is concluded that coronary artery bypass graft can be performed with morbidity and mortality equivalent to percutaneous transluminal coronary angioplasty, and provides better cardiac event-free rates than percutaneous transluminal coronary angioplasty in patients on hemodialysis. Percutaneous transluminal angioplasty does not appear to be justified in this population because of its unacceptably high restenosis and cardiac event rates.     

Accelerated graft disease in a composite saphenous vein with internal thoracic artery in a chronic renal dialysis patient

A 59-year-old man with 18-year history of renal dialysis due to chronic nephritis suffered coronary artery disease, which was complete occlusion of the right coronary artery and diffuse 90% stenosis of the proximal left anterior descending artery. Off-pump coronary artery bypass grafting was performed. Saphenous vein (SV) was anastomosed with left internal thoracic artery (ITA) as a T-graft. Left ITA was anastomosed to the left anterior descending artery. The end of SV was sewn on the posterior descending artery. Coronary and graft angiography performed 2 weeks after the operation showed good patency with good distal run-off of both left ITA and SV. Three months after the operation, he was admitted with unstable angina. Angiography revealed accelerated SV graft stenosis without any change of prior coronary disease. However, angiography 7 months after the operation revealed complete obstruction of the S V graft when he was admitted because of recurrent anginal pain.