Mortality risk factors in chronic renal failure patients after coronary artery bypass grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p 相似文献   

Coronary Artery Bypass Grafting in Patients with Chronic Renal Failure:A Reappraisal

A bstract Background and Aims : Chronic renal failure (CRF) is known to increase the morbidity and mortality in patients undergoing cardiac operations. Successful outcome of coronary artery bypass grafting (CABG) in some patients with CRF has been reported, but remains controversial. Methods : Forty-four patients with CRF who underwent CABG were examined. Two groups were analyzed. Group I consisted of 13 patients with end-stage renal disease on hemodialysis. Group II consisted of 31 patients with a creatinine ± 1.6 gm/dL for a minimum of 6 months, but were not on dialysis. There were 36 male and 8 female patients, with a mean age of 71 years. Results : The hospital mortality was 10 patients (23%) with 4 (31%) hospital deaths in Group I, and 6 (19%) in Group II. There was major morbidity in 35 (80%) patients. In Group II there were 8 (26%) patients who required permanent postoperative dialysis. A control group of 547 patients 70 years of age who underwent CABG had 30 hospital mortalities (5%) and 75 morbidities (13%). The average length of stay was 27 days. Fifteen patients died at a mean of 34 months after being discharged from the hospital. Nineteen of the original 44 patients remain alive at a mean of 32 months. The total mortality at 6 years and 4 months was 57%. Conclusions : Older and sicker patients with CRF who undergo CABG are at an exceptionally high risk for mortality and morbidity. For CRF patients not on dialysis with a creatinine 2.5 gm/dL, there is a strong likelihood of permanent postoperative dialysis. Long-term follow-up shows survival to be well below their non-CRF counterparts.     

Concomitant Carotid Endarterectomy and Coronary Bypass Surgery: Should Cardiopulmonary Bypass Be Used for the Carotid Procedure?

Abstract Background and Objectives: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. Patients and Methods: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. Results: CPB time was significantly longer in Group I, 127 ± 21 minutes versus 98 ± 11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. Conclusions: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.     

Coronary artery bypass grafting for hemodialysis-dependent patients

Patients with end-stage renal disease carry a risk of coronary atherosclerosis. This study was performed to evaluate the perioperative and remote data of coronary artery bypass grafting (CABG) in hemodialysis dependent patients. We retrospectively analyzed the results of isolated CABG performed at Shin-Tokyo Hospital between June 1, 1993 and May 31, 2000. Preoperative, perioperative, and follow-up data of the patients on hemodialysis (Group HD, n = 37) were collected and compared with those of control patients (Group C, n = 1,639). Group HD consisted of 26 males and 11 females with a mean age of 59.9 +/- 8.1 years, and the mean number of bypasses was 2.5 +/- 1.1. Group HD had a longer postoperative intubation time, ICU stay, and hospital stay than Group C. The postoperative major complication rate in Group HD (18.9%) was not significantly different from that in Group C (11.3%). However, the inhospital mortality rate in Group HD (5.4%) was higher than Group C (0.6%). At the mean follow-up of 2.4 years, the actuarial 3-year survival of Groups HD and C were 90.6% and 97.6%, respectively (p < 0.001), excluding hospital mortality. The actuarial 3-year cardiac event-free rates were 84.3% in Group HD and 88.8% in Group C, showing no difference. Patients on chronic hemodialysis carry a significant risk of prolonged inhospital care and hospital death. Once successful surgical revascularization was completed, their long-term cardiac events could be controlled as effectively. The increased distant death rates was probably associated with the nature of renal disease.     

CARDIAC ARRHYTHMIAS AND SILENT MYOCARDIAL ISCHEMIA DURING HEMODIALYSIS

Cardiac arrhythmias are noted in a significant proportion of chronic renal failure (CRF) patients on hemodialysis (HD), and may contribute to cardiovascular mortality. A number of factors have been implicated in the genesis of these arrhythmias. The role of silent myocardial ischemia (SMI), however, has not been evaluated systematically. We prospectively studied 38 unselected CRF patients on regular HD by continuous Holter monitoring starting 24 hours before HD, lasting through the dialysis session and continued for 20 hours thereafter. The recordings were analyzed for frequency, timing and severity of supraventricular and ventricular arrhythmias and SMI as identified by ST-segment depression. Ventricular arrhythmias during HD were noted in 11 (29%) patients (group I), and were potentially life-threatening (Lown Class III and IVa) in 13%. The remaining 27 patients (group II) had no ventricular arrhythmias during HD. There was no difference in the age, sex ratio, duration of HD, blood pressure, fluctuations in weight, hematocrit, predialysis creatinine, sodium, potassium, calcium or inorganic phosphate levels between patients in the two groups. The number of patients with clinical ischemic heart disease was significantly greater in group I. SMI was noted in 72% and 33% of group I and II patients respectively (p =0.026). 46% of those with and 25% of those without ST changes during HD developed ventricular arrthythmias during HD. Both SMI and ventricular arrhythmias were noted most frequently during the last hour of dialysis. Hypertension, diabetes mellitus and ischemic heart disease were observed more frequently amongst patients with SMI. Ventricular arrhythmias are detected in a significant proportion of CRF patients on HD. These are probably related to coronary artery disease since silent myocardial ischemia is also noted more frequently during HD in these patients. Further studies incorporating coronary angiography are needed in a larger number of patients to establish a definite causal relationship.     

Coronary artery bypass graft operations can be performed safely in obese patients.

OBJECTIVES: Obesity is a major public health problem with an increasing prevalence. Although coronary artery bypass grafting (CABG) operations are now performed with low morbidity and mortality rates, obesity is still assumed to be an important risk factor for morbidity and mortality at these operations but there is no precise approach to define it as a risk factor. The aim of this study is to evaluate the effects of obesity on the clinical outcome of the CABG operations. METHODS: A total of 1206 patients, who underwent isolated CABG operation under cardiopulmonary bypass were evaluated retrospectively. The patients were divided into three groups. Group I was normal weight, with body mass index (BMI) of 18-24.9 kg/m(2), group II was overweight, with a BMI of 25-29.9 kg/m(2), and group III was obese, with a BMI of >30 kg/m(2). The clinical data of three groups were evaluated in aspects of postoperative morbidity and mortality. RESULTS: Except for the superficial wound infections, there were no differences in postoperative mortality and morbidity rates between the three groups. Obesity was not found to be an important risk factor for postoperative morbidity and mortality. CONCLUSIONS: Despite the perception that obesity increases the risk of mortality and morbidity in CABG operations, the clinical outcome of these patients are not so different from other patients. We may say that obese patients can be safely operated.     

The mid-term outcome of geometric endoventricular repair for the patients with ischemic left ventricular dysfunction.

OBJECTIVE: Recent studies have suggested that increased left ventricular (LV) size is a risk factor for perioperative mortality in patients with low ejection fraction (EF) undergoing coronary artery bypass surgery (CABG). We previously presented a new method of LV reconstruction, called geometric endoventricular repair (GER) as representing a physiologically effective repair. The aim of this study is to assess whether GER confers benefits compared to patients undergoing CABG alone. METHODS: Between July 1996 and July 2001, 110 patients with a low EF of less than 35% documented by radionuclide ventriculogram (RNVG) underwent CABG in Austin Hospital, Australia, and were divided into two groups. Group I consisted of 52 patients undergoing isolated CABG. Group II comprised 58 patients undergoing CABG and GER. We compared the two groups in terms of EF, NYHA class, incidence of recurrent heart failure, and mortality. RESULTS: Preoperative EF was 27.7+/-6.1% in group I and 27.4+/-5.7% in group II, respectively (NS), with significant improvement in both groups (33.8+/-13.0% in group I, 35.1+/-13.3% in group II). NYHA class was also significantly improved postoperatively (from 3.3 to 1.8 in group I, and 3.6 to 1.7 in group II). There were 15 patients (28.8%) hospitalized for heart failure in group I, postoperatively, compared to seven patients (10.9%) in group II (p=0.026). Cardiac event-free survival rate at 28 months (mean follow-up) was also significantly higher in group II (88.9% in group II vs. 70.6% in group I, p=0.05). The actuarial survival rate at 31 months (mean follow-up) was 88.2% in group I and 95.3% in group II, respectively (NS). CONCLUSIONS: LV reconstruction along with CABG for ischemic ventricular dysfunction may provide symptomatic and cardiac event free survival benefits, compared to CABG alone.     

Surgical results of Stanford type B aortic dissection. Comparisons between partial and subtotal replacement of the dissected aorta

BACKGROUND: Surgical results for Stanford type B aortic dissection were retrospectively compared between the subtotal prosthetic replacement of the thoracoabdominal dissected aorta (STR) and partial replacement of the descending aorta at the intimal tear (PR). METHODS: Twenty-two patients (11 males and 11 females with mean age of 56.9+/-2.6 years) undergoing repair of aneurysms were analyzed. All operations were performed with the aid of femorofemoral partial cardiopulmonary bypass. Reconstruction of the critical artery for spinal cord blood supply was determined by evoked spinal cord potential (ESP) monitoring in non-urgent cases. Operative mortality and incidence of complications were compared between the PR group (Group I; n=15) and the STR group (Group II; n=7). RESULTS: There were one operative death and one late death in Group I. No early or late deaths occurred in Group II. Postoperative paraplegia occurred in 1 patient in Group I and 2 patients in Group II. Among patients undergoing selective reconstruction of the critical intercostal arteries, paraplegia occurred in only one patient. Incidence of postoperative complications was not significantly different between Group I and Group II. Presence of rupture (p<0.001) and development of acute renal failure (p<0.05) revealed significant determinants of postoperative mortality by multivariate analysis. Operative procedure did not influence postoperative mortality or occurrence of paraplegia. CONCLUSIONS: Operative results of STR with selective reconstruction of the critical arteries and PR for aortic dissection were comparable. Subtotal replacement of the thoracoabdominal dissected aorta is encouraged to apply for patients with diffuse, large postdissection aneurysms or those with a high risk of future enlargement of remaining false channels such as Marfan syndrome, under adequate reconstruction of the critical segmental arteries.     

Does On‐Pump/Beating‐Heart Coronary Artery Bypass Grafting Offer Better Outcome in End‐Stage Coronary Artery Disease Patients?

OBJECTIVES: The purpose of our study was to evaluate in a cohort of end-stage coronary artery disease (ESCAD) patients the effects of on-pump/beating-heart versus conventional coronary artery bypass grafting (CABG) requiring cardioplegic arrest. We report early and midterm survival, morbidity, and improvement of left ventricular (LV) function. METHODS: Between January 1992 and October 1999, 107 (Group I) ESCAD patients underwent on-pump/beating-heart surgery and 191 (Group II) ESCAD patients underwent conventional CABG requiring cardioplegic arrest. Mean age in Group I was 65.8 +/- 6.5 years (58-79 years); New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classifications were 3.2 +/- 0.4 and 3.3 +/- 0.5, respectively. LV ejection fraction (LVEF) was 24.8% +/- 4%, LV end diastolic pressure (LVEDP) was 28.2 +/- 3.8 mmHg, and LV end diastolic diameter (LVEDD) was 69.6 +/- 4.6 mm. Mean age in Group II was 64.1 +/- 5 years (57-76 years), NYHA class was 3 +/- 0.6, CCS class was 3.4 +/- 0.4, LVEF was 26.2% +/- 4.3%, LVEDP was 27.2 +/- 3.4 mmHg, and LVED was 68 +/- 4.2 mm. RESULTS: Preoperatively, Group I patients versus Group II patients had a markedly depressed LV function (LVEF, p = 0.006; LVEDP, p = 0.02; LVEDD, p = 0.003; and NYHA class, p = 0.002), older age (p = 0.012), and higher incidences of multiple acute myocardial infarction (AMI; p = 0.004), cardiovascular disease (CVD; p = 0.008), and chronic renal failure (CRH, p = 0.002). Cardiopulmonary bypass (CPB) time was longer in Group II patients (p = 0.028). The mean distal anastomosis per patient was similar between groups (p = NS). Operative mortality between Groups I and II was 7 (6.5%) and 19 (10%), respectively (p = NS). Perioperative AMI (p = 0.034), low cardiac output syndrome (LCOS; p = 0.011), necessity for ultrafiltration (p = 0.017), and bleeding (p = 0.012) were higher in Group II. Improvement of LV function within 3 months after the surgical procedure was markedly higher in Group I, demonstrated by increased LVEF (p = 0.035), lower LVEDP (p = 0.027), and LVEDD (p = 0.001) versus the preoperative data in Group II. The actuarial survivals at 1, 3, and 5 years were 95%, 86%, and 73% in Group I and 95%, 84%, and 72% in Group II (p = NS). CONCLUSIONS: ESCAD patients with bypassable vessels to two or more regions of reversible ischemia can undergo safe CABG with acceptable hospital survival and mortality and morbidity. In higher risk ESCAD patients, who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers better myocardial and renal protection associated with lower postoperative complications.     

Concomitant carotid endarterectomy and coronary bypass surgery: should cardiopulmonary bypass be used for the carotid procedure?

BACKGROUND AND OBJECTIVES: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. PATIENTS AND METHODS: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. RESULTS: CPB time was significantly longer in Group I, 127+/-21 minutes versus 98+/-11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. CONCLUSIONS: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.     

Beating heart myocardial revascularization on extracorporeal circulation in patients with end-stage coronary artery disease

OBJECTIVES: To evaluate in a cohort of ESCAD patients (pts) the effects of on-pump/beating-heart versus conventional CABG in terms of early and mid-term survival and morbidity and LV function improvement. METHODS: Between January 1993 and December 2000, 78 (Group I) ESCAD pts underwent on-pump/beating-heart surgery. Mean age in Group I was 66.2+/-6 (58-79), NYHA and CCS class were 3.2+/-0.6 and 3.3+/-0.4 respectively, Myocardial viability index 0.69+/-0.1 (%), LVEF (%) 24.8+/-4, LVEDP (mmHg) 28.1+/-5.8 and LVEDD(mm) 69.5+/-6. Group II consisted in 78 ESCAD patients undergoing conventional CABG selected in a randomized fashion from an age, sex, and LVEF corrected group of patients. Mean age in Group II was 65.7+/-5 (57-78), NYHA 3.1+/-0.7, CCS 3.4+/-0.8, LVEF(%) 25+/-5, LVEDP(mmHg) 27.9+/-4.4 and LVEDD(mm) 69.2+/-7.2. RESULTS: Postoperatively, 5(7.7%) patients died in Group I versus 7(11.5%) patients in Group II (P>0.1). CPB time resulted to be in Group II patients (P=0.001) and the mean distal anastomoses per patient was similar between groups (P=Ns). Perioperative AMI (P=0.039), LCOS (P=0.002), necessity for ultrafiltration (P=0.018) and bleeding>1000 ml (P=0.029) were significantly higher in Group II. None of the Group I patients underwent surgical revision for bleeding versus 8(10.3%) patients in Group II (P=0.011). At 6 months after surgery, the LV function improved significantly in Group I patients, demonstrated by an increased LVEF=27.2+/-4(%)(P=0.001), lower LVEDP=26.4+/-3(mmHg)(P=0.029) and LVEDD=67+/-4(mm) (P=0.004) instead of a lower LVEDD=66.8+/-6(mm)(P=0.032) versus the preoperative data in Group II. The actuarial survival at 1, 3 and 5 yr were 90, 82 and 71% in Group I and 89, 83 and 74% in Group II (P=Ns). CONCLUSION: In ESCAD patients who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers a better myocardial and renal protection associated with lower postoperative complications due to intraoperative hypoperfusion.     

The role of coronary angiography in acute type A aortic dissection.

OBJECTIVES: In recent years, non-invasive methods have replaced angiography in the diagnosis of aortic dissection. Angiography maybe used to evaluate coexisting coronary artery disease (CAD), which can delay surgery and increase the risk of rupture. We set out to examine the role of angiography in acute aortic dissection. METHODS: A retrospective analysis of patients who underwent repair of acute aortic dissection between January 1992 and June 2002 was conducted. The effect of angiography on the need for concomitant coronary artery surgery (CABG), delay to surgery and outcome were analysed. RESULTS: Seventy-four patients were identified. Initial diagnosis was established by non-invasive techniques. Twenty-three patients (31%) underwent angiography (Group I) in three this was unsuccessful. Three in Group I and four in the non-angiography group (Group II, n=51) had history of angina. One patient in Group I underwent concomitant CABG compared to seven in Group II. The patient who underwent CABG in Group I; and four out of seven in Group II died (NS). Patients who underwent concomitant CABG had a significantly higher mortality rate (P=0.04). Mortality in Group I was 35% (n=8) and in Group II was 29% (n=15) (NS). Mortality rate was also significantly higher in patients who presented with syncope (P=0.01) or hypotension (P=0.04). Median transfer time from arrival at our centre to the operating room was 5 h in Group I and 1.5 h in Group II (P<0.001). Mortality rate was higher in patients who took longer to transfer to the operating room, but this did not reach statistical significance. CONCLUSIONS: We have shown that coronary angiography did not affect the occurrence of CABG and was not associated with improved hospital survival. Furthermore, there is a considerable delay to surgery caused by angiography. Therefore in this setting coronary angiography is not recommended.     

Beating heart ischemic mitral valve repair and coronary revascularization in patients with impaired left ventricular function

OBJECTIVE: The aim of this study is to evaluate in a cohort of patients with impaired left ventricular (LV) function and ischemic mitral valve regurgitation (MVR), the effects of on-pump/beating heart versus conventional surgery in terms of postoperative mortality and morbidity and LV function improvement. MATERIALS AND METHODS: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III-IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 +/- 7 years and in Group II, 65 +/- 6 years (p = 0.69). RESULTS: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 +/- 1 and 2.7 +/- 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 +/- 6 (%) versus 16 +/- 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. CONCLUSION: We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients.     

Intermediate Clinical Results of Combined Gastroepiploic and Internal Thoracic Artery Bypass

Background. To improve the postoperative results of coronary artery bypass grafting (CABG), the internal thoracic artery (ITA) has become the conduit of choice, with a low operative risk. The gastroepiploic artery as a third arterial conduit for grafting was first reported in 1987, and the early results were reported to be as good as those for the ITA graft. In this report, we present the intermediate-term results of combining ITA and gastroepiploic artery grafts up to 7 years after the operation.

Methods. Between April 1988 and April 1992, 214 patients received CABG with at least one ITA graft and were followed up for more than 3 years. They were divided into two groups: Group I consisted of 155 patients who had CABG using one ITA with or without saphenous vein grafts, and group II consisted of 59 patients who had CABG using an ITA and a gastroepiploic artery with or without saphenous vein grafts. The duration of follow-up for hospital survivors ranged from 36 to 89 months.

Results. There were six late cardiac deaths in group I and one in group II. Fifteen patients complained of recurrent symptoms of angina: 13 in group I and 2 in group II. The actuarial survival rate excluding noncardiac deaths was 95.9% in group I and 96.8% in group II at 7 years (p = not significant). The cardiac event-free rate was 75.4% in group I and 92.2% in group II, which was a significant difference (p < 0.05).

Conclusions. When using both the ITA and gastroepiploic artery, CABG can be performed with minimal operative risk and seems to offer an improved quality of life at least 7 years postoperatively.     

Association Between Attributed Cause of End-Stage Renal Disease and Risk of Death in Brazilian Patients Receiving Renal Replacement Therapy

Background. Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). Objectives. This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. Methods. We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. Results. Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR = 0.73, 95% CI: 0.65–0.83, p< 0.0001); 29% lower in patients with GN (RR = 0.71, 95% CI: 0.68–0.74, p< 0.0001); and 100% greater in DM patients (RR = 2.00, 95% CI: 1.92–2.10, p< 0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. Conclusions. Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

Does the clinical evaluation of the cardiac status predict outcome in patients with abdominal aortic aneurysms?

A cost-effective method to reduce mortality rates after abdominal aortic aneurysm repair centers on selecting and investigating only those patients at risk for cardiac-related death. All 146 patients undergoing asymptomatic abdominal aortic aneurysm repair over a 5-year period (1986 to 1990) were retrospectively placed into one of the three following groups on the basis of a clinical evaluation. Group I: no history of myocardial infarction or angina, no congestive heart failure, and no ischemic changes on electrocardiogram (ECG). Group II: history of myocardial infarction or class I-II angina or ischemic changes on ECG. Group III: presence of congestive heart failure or class III-IV angina. Patients in group I had no further cardiac work-up; patients in group II with angina had left ventricular ejection fraction assessment by multiple gated acquisition (all greater than 37%) and were cleared for operation by a cardiologist; patients in group II without angina had no further cardiac work-up; patients in group III had coronary angiography and then coronary revascularization. The overall mortality rate was 4.8%, with a cardiac mortality rate of 3.4%. The mortality rate in group I (n = 64) was 1.8%, with no cardiac-related deaths; the mortality rate in group II (n = 63) was 9.5% (8% cardiac-related deaths). No deaths occurred in group III (n = 19). The difference between the cardiac mortality rates in groups I and II was significant (p = 0.02) as was the postoperative cardiac morbidity: total myocardial infarctions (p less than 0.001); congestive heart failure (p = 0.02); tachyarrhythmias (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS

Longer treatment time (TT) and slower ultrafiltration rate (UFR) are considered advantageous for hemodialysis (HD) patients. The study included 22,000 HD patients from seven countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Logistic regression was used to study predictors of TT > 240 min and UFR > 10 ml/h/kg bodyweight. Cox regression was used for survival analyses. Statistical adjustments were made for patient demographics, comorbidities, dose of dialysis (Kt/V), and body size. Europe and Japan had significantly longer (P < 0.0001) average TT than the US (232 and 244 min vs 211 in DOPPS I; 235 and 240 min vs 221 in DOPPS II). Kt/V increased concomitantly with TT in all three regions with the largest absolute difference observed in Japan. TT > 240 min was independently associated with significantly lower relative risk (RR) of mortality (RR = 0.81; P = 0.0005). Every 30 min longer on HD was associated with a 7% lower RR of mortality (RR = 0.93; P < 0.0001). The RR reduction with longer TT was greatest in Japan. A synergistic interaction occurred between Kt/V and TT (P = 0.007) toward mortality reduction. UFR > 10 ml/h/kg was associated with higher odds of intradialytic hypotension (odds ratio = 1.30; P = 0.045) and a higher risk of mortality (RR = 1.09; P = 0.02). Longer TT and higher Kt/V were independently as well as synergistically associated with lower mortality. Rapid UFR during HD was also associated with higher mortality risk. These results warrant a randomized clinical trial of longer dialysis sessions in thrice-weekly HD.     

The association of interdialytic weight gain with nutritional parameters and mortality risk in hemodialysis patients

High interdialytic weight gain (IDWG) is considered as an indicator of noncompliance but could also be interpreted as an index of appetite. This study was designed to investigate the relationship IDWG with malnutrition and mortality risk in hemodialysis (HD) patients through a follow-up of 24 months. We divided HD patients into two groups according to their IDWG as Group I (IDWG < 3% of dry weight/day) (27 patients; age 46.8 +/- 21.1 years; HD duration: 28.3 +/- 39.5 months) and Group II (IDWG > or = 3% of dry weight/day) (41 patients; age 40.9 +/- 11.3 years; HD duration: 54.7 +/- 38.7 months). We investigated malnutrition through biochemical analysis (albumin, prealbumin, total cholesterol, creatinine, predialysis potassium and phosphorus levels), normalized protein catabolic rate (nPCR), anthropometric measurements. On initial assessment, group I had significantly lower predialysis creatinine, prealbumin and potassium levels than Group II (p < 0.0001, p < 0.01 and p < 0.001, respectively). At the 24th month, there were significantly lower creatinine, prealbumin, potassium and phosphorus levels in the low-IDWG group. Group I had significantly lower nPCR, body weight, body mass index and triceps skinfold thickness during the follow-up. Over the 24 months, 13 (48.1%) Group I patients and nine (21.9%) Group II patients exhibited loss of dry weight (p < 0.02). According to the survival curves prognosis was significantly poorer for Group I than Group II (2-year survival 74.0% and 92.6%, p < 0.03). Group I individuals with low albumin levels had the worst survival rate (57.1%). In conclusion there is a strong association of IDWG with nutritional parameters in HD patients. Our study draws attention for a possible risk of developing malnutrition in a HD patient with low IDWG.     

Transplantation versus coronary artery bypass in patients with severe ventricular dysfunction. Surgical outcome and quality of life

BACKGROUND: The purpose of this study is to evaluate the quality of life, functional status and survival rate of patients with left ventricular ejection fraction (LVEF) < or = 20% following coronary bypass (CABG) versus heart transplantation. METHODS: Experimental design: comparative study, mean follow-up of 20 months. Setting: division of cardiac surgery at a McGill University-based hospital in Montreal, Canada. Patients: the charts of 65 consecutive patients with angiographic LVEF < or = 20% were reviewed. Among these patients, 14/65 were referred for transplantation but instead underwent CABG (Group I) after consultation with the transplant committee. The charts of 14 matched transplant patients (Group II) were reviewed. The SF-36 and Duke's questionnaire forms were mailed to both groups in order to evaluate their quality of life and functional capacity, respectively. Interventions: comparison between coronary bypass and heart transplantation. Measures: main outcome measures were mortality, quality of life, and functional capacity. RESULTS: Results are expressed as mean+/-SEM. The in-hospital mortality rate of CABG among all patients with LVEF < or = 20% was 4.6% (3/65). Among the 14 CABG patients initially referred for transplantation, perioperative mortality was 1/14 (7.1%), same as in the matched transplant group. Three additional group I patients were reported by family to have died of cardiac events at follow-up period. Postoperative death identified at follow-up was assigned the lowest life quality score. The transformed quality of life scores were as follows: physical functioning: I=42.5+/-10.6, II=73.2+/-7.2, p=0.029; physical role: I=35.0+/-13.5, I=61.4+/-13.2, p=0.180; bodily pain: I=54.0+/-14.0, II=69.8+/-8.5, p=0.349; general health: I=34.7+/-9.2, II=84.6+/-5.2, p=0.0003; vitality: I=36.5+/-9.3, II=60.0+/-5.2, p=0.045; social functioning: I=55.0+/-4.0, II=87.5+/-5.1, p=0.050; emotional role: I=36.7+/-15.3, II=87.9+/-6.8, p=0.009; mental health: I=52.8+/-12.4, II=81.5+/-4.2, p=0.054. Duke's activity status index: I=16.8+/-4.2, II=31.8+/-4.2, p=0.021. CONCLUSIONS: Heart transplant is associated with a significantly superior postoperative quality of life and functional capacity than bypass surgery. However, in patients with LVEF < or = 20%, CABG can be performed with an acceptable perioperative mortality of 4.6%-7.1%, similar to the rate for transplantation.     

Heart Rate Variability,Left Ventricular Functions,and Cardiac Autonomic Neuropathy in Patients Undergoing Chronic Hemodialysis

Objective.?Autonomic neuropathy and impairment of left ventricular functions (LVF) have been frequently encountered in chronic renal failure (CRF). The aim of the present study was to evaluate the relationship of cardiac autonomic modulation impairments, as assessed by means of heart rate variability (HRV), with clinical characteristics, and left ventricular function in the patients with CRF undergoing hemodialysis (HD). Methods.?Twenty control subjects (Group I) and 22 comparable by age and gender patients with CRF undergoing hemodialysis (Group II) were enrolled in the study. After routine clinical and biochemical evaluations, electrocardiography, and 2 Dimensional, M Mode echocardiography were performed in all participants. Frequency domain HRV analysis was studied by using Kardiosis System. The powers (P₁ and P₂) and the central frequencies (F₁ and F₂) of low and of high frequency spectral bands were recorded. Results.?End systolic (ESV) and end diastolic volumes (EDV) were significantly higher in Group II (59.3 ± 21.1 mL vs. 34.0 ± 14.3 mL and 131.5 ± 37.3 mL vs. 96.9 ± 18.9 mL, p<0.01, p<0.05, respectively) when compared to those of Group I. Ejection fraction (EF) and fractional shortening (FS) were significantly lower in Group II than in control subjects (52.3 ± 2.4% vs. 63.7 ± 10.1% and 0.29 ± 0.01 vs. 0.34 ± 0.07, p<0.001, p<0.05, respectively). P1 and P2 were decreased in Group II than in Group I (136.2 ± 173.9 m s² vs. 911.0 ± 685.5 and 96.5 ± 149.6 vs. 499.7 ± 679.5, p<0.001, p<0.01, respectively). Significant correlations were found between high frequency spectral power and dialysis duration (DD), ESV, EDV, EF, FS (r = 0.52 p<0.01, r = 0.68 p<0.001, r = 0.65 p<0.002, r = 0.66 p<0.02, and r = 0.69 p<0.01). Conclusion.?As a result, the dependence of cardiac autonomic neuropathy on the disease duration and degree of left ventricular function impairment was shown in the patients undergoing chronic hemodialysis.