Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction

Patients with severe left ventricular systolic dysfunction (LVSD) undergoing coronary artery bypass grafting (CABG) have an increased risk for morbidity and mortality. The purpose of this study was to assess the association of pre-CABG right ventricular (RV) function with outcome for patients with severe LVSD. We performed a retrospective evaluation of 41 patients with severe LVSD (left ventricular ejection fraction [LVEF] < or =25%) scheduled for nonemergent CABG. Data were obtained from review of medical records, transesophageal echocardiography tapes, and phone interview. The pre- and post-cardiopulmonary bypass (CPB) LVEF and the RV fractional area of contraction (RVFAC) were calculated by using intraoperative transesophageal echocardiography. Group 1 patients had an RVFAC < or =35% (n = 7), whereas Group 2 patients had RVFAC >35% (n = 34). The durations of mechanical ventilation and of intensive care unit and hospital stays are presented as the median. Pre-CABG LVEF was similar between Groups 1 and 2 (15.8% +/- 3.3% versus 17.8% +/- 3.9%). Compared with Group 2, Group 1 patients required greater duration of mechanical ventilation (12 days versus 1 day; P < 0.01), longer intensive care unit (14 versus 2 days; P < 0.01) and hospital (14 versus 7 days; P = 0.02) stays, had a more frequent incidence and severity of LV diastolic dysfunction, and had a smaller change in LVEF immediately after CPB (4.1% +/- 8.3% versus 12.5% +/- 9.2%; P = 0.03). All Group 1 patients died of cardiac causes within 2 yr of surgery; five died during the same hospital admission. Three Group 2 patients died: one of colon cancer at 18 mo after CABG and two of cardiac causes 24 and 48 mo after surgery. A fourth patient was awaiting cardiac transplantation 4 yr after surgery. The remaining Group 2 patients were New York Heart Association Classification I or II. For patients with severe LVSD undergoing CABG, pre-CPB RV dysfunction was associated with poor outcome. Patients with RVFAC >35% had a relatively uneventful perioperative course and good long-term survival, whereas patients with RVFAC < or =35% had a poor early and late outcome. Assessment of RV function is useful to further assess the risk of CABG. IMPLICATIONS: Right ventricular function before cardiopulmonary bypass is associated with poor outcome after coronary artery surgery in patients with poor left ventricular function.     

Long term left ventricular systolic function assessment following CABG. A prospective, randomised study. Blood versus cristalloid cardioplegia

BACKGROUND: In an effort to define the role of blood cardioplegia delivered in antegrade/retrogade fashion in patients with either good or poor left ventricular function undergoing elective coronary artery bypass surgery, we initiated a prospective randomised study in which postoperative hemodynamics besides clinical data were compared in patients administered antegrade/retrograde crystalloid cardioplegia. METHODS: To compare the efficiency of two methods of myocardial protection--cold crystalloid ante/retro cardioplegia and cold blood ante/retro cardioplegia in two groups of patients with high and low LVEF--we randomised 122 patients for CABG. The potential improvement in left ventricular systolic function assessed by echocardiography and the same clinical data were the end points of the study. Patients were divided into group I (47 patients, LVEF <40%) and group II (75 patients, LVEF >40%). Pathologic antecedents and preoperative clinical conditions were similar in both randomised subgroups Ia, IIa (crystalloid cardioplegia) and subgroups Ib, IIb (blood cardioplegia). The following parameters were measured: left atrium diameter (LA), left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD), left ventricular ejection fraction (LVEF), left ventricular wall motion score index (WMSI), and area asynergy (AA). All patients underwent echocardiography: A--prior the CABG, B--2-6 weeks postoperatively, C--3 months postoperatively, D--6 months postoperatively, E--1 year postoperatively. RESULTS: The results of clinical assessment in both groups showed improvement of quality of life. The constant improvement of LVEF and WMSI was observed in group I in contrast to group II. There were no significant differences in postoperative left ventricular systolic function between subgroups Ia and Ib or IIa and IIb. CONCLUSIONS: The use of blood cardioplegia, instead of crystalloid cardioplegia, when used in the ante/retrograde fashion during CABG has no influence on postoperative left ventricular systolic function. The improvement in left ventricular systolic function following CABG is greater in patients with low LVEF in contrast to patients with high LVEF.     

Right ventricular dysfunction after coronary artery bypass grafting is a reality of unknown cause and significance

Objective: To evaluate the impact of coronary bypass surgery on the function of the right ventricle (RV) in patients with a pre-operative ejection fraction ≥ 35% who did not have any perioperative myocardial infarction.Method: We performed a prospective study of 30 patients who underwent uneventful isolated coronary artery bypass grafting (CABG). All patients had echocardiography prior to surgery and 3 months postoperatively. Myocardial tissue Doppler velocities were used to measure left and right ventricular function. The right ventricular myocardial performance index (Tei) and the ratio between the velocities of the RV and left ventricle (LV) were also calculated.Results: There was a significant improvement in left ventricular ejection fraction before and after CABG (P = .046). The tissue Doppler imaging (TDI) velocities from the LV remained unchanged, but highly significant reductions in right ventricular TDI velocities were observed (P <.001). The TDI peak systolic (S), early diastolic (E), and late diastolic (A) velocities had a reduction of 30%, 34.5%, and 20%, respectively. Similarly, a fall in RV to LV ratios of various TDI velocities was also observed. This was also accompanied by a significant rise in the RV Tei index. All of these findings are suggestive of significant RV dysfunction.Conclusion: There is a marked impairment of RV function after CABG.     

室壁瘤切除左心室几何重建连续42例经验

目的总结42例室壁瘤切除左心室成形加冠状动脉搭桥无死亡的经验. 方法 42例左心室室壁瘤患者,男41例、女1例,平均年龄(55.5±2.4)岁(40～68岁).38例有不稳定性心绞痛,术前合并严重室性心律失常10例,其中有心室颤动病史2例,反复发作室性心动过速8例,合并高血压病26例,糖尿病3例,重症慢性阻塞性肺疾病1例;心功能(NYHA)Ⅲ级32例,Ⅳ级10例;合并二尖瓣轻至中度关闭不全6例.42例经左心室造影和手术证实为解剖性室壁瘤,位于前间壁41例、下壁1例.左心室射血分数(LVEF)平均41%(17%～63%),其中LVEF<40%29例.33例采用Jatene术式,8例Dor术式, 1例Cooley术式,其中10例在心脏跳动下完成左心室成形术.左主干病变7例,3支病变30例,2支病变6例,单纯左前降支病变5例.全部患者同期行冠状动脉搭桥术,乳内动脉使用率100%.术中证实左心室内附壁血栓21例.平均体外循环时间(135±11)min,阻断升主动脉(78±10)min. 结果术后平均住院天数(13.1±1.2)d,住ICU(2.8±0.6)d.使用主动脉内气囊反搏7例(17%),术后发生顽固性室性心动过速1例,胸骨哆开1例,术后早期渗血、二次开胸止血1例.术后左心室前后径、舒张末期和收缩末期容量较术前明显缩小(P<0.05),LVEF有增加趋势(P>0.05).围手术期无死亡,均痊愈出院.术后随访10个月至4年,无死亡. 结论室壁瘤切除左心室几何重建术同期行冠状动脉旁路术,除改善心功能外,可消除室性心动过速,手术安全、可靠,效果良好.     

Beneficial effects of ischemic preconditioning on right ventricular function after coronary artery bypass grafting

BACKGROUND: Preservation of right ventricular myocardium is unsatisfactory in patients with critical stenosis or occlusion of the right coronary artery. The aim of this study was to investigate whether ischemic preconditioning (IP) improved the recovery of right ventricular function after coronary artery bypass grafting. METHODS: Forty patients with three-vessel disease who had coronary artery bypass grafting were randomly assigned to the IP group (n = 20) or control group (n = 20). In the IP group, two cycles of two minutes of ischemia after three minutes of reperfusion were given before cross-clamping. Hemodynamic data were collected. Right ventricular ejection fraction was measured by thermodilution. RESULTS: Right ventricular ejection fraction and right ventricular systolic volume index were decreased post-operatively (lowest value at 6 hours postoperatively). The changes in right ventricular ejection fraction were significantly milder in the IP group postoperatively (p = 0.012). The decrease in right ventricular systolic volume index postoperatively was also less in IP patients (p = 0.002). Fewer inotropic drugs were used in the IP group compared with controls. CONCLUSIONS: Ischemic preconditioning had a myocardial protective effect on recovery of right ventricular contractility in patients who had coronary artery bypass grafting.     

Multivessel off-pump revascularization in patients with severe left ventricular dysfunction.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of multivessel beating heart revascularization in a high-risk group of patients with severe left ventricular dysfunction as well as to provide intermediate survival and quality of life data. METHODS: Our prospectively updated database was queried to extract all patients with left ventricular ejection fraction < or =30% who underwent beating heart revascularization. Standard demographics, clinical profiles and outcomes were collected. Outcomes were compared with Society of Thoracic Surgeons (STS) benchmarks for all coronary artery bypass grafting (CABG) patients. Telephone interviews were conducted and survival and quality of life data were tabulated. In addition, morbidity and mortality outcomes were compared with a concurrent cohort of patients with similarly impaired left ventricular function who underwent conventional coronary artery bypass. RESULTS: One hundred off-pump coronary artery bypass grafting patients were identified and follow-up was 93% complete in these patients. Mean age was 67+/-10.5 years and mean ejection fraction was 26+/-4%. Twenty-one percent were females. Balloon counterpulsation support was used liberally in the perioperative period. Patients received a mean of 3.5 grafts with 83% internal mammary artery use. Observed mortality was 3% with a predicted mortality of 5.3%. Observed to expected ratio was 0.56. Incidence of adverse events compared favorably with both that reported in the STS for all CABG patients regardless of left ventricular function, and also to a concurrent CABG cohort. One-year survival was 85%. Freedom from cardiac readmission was 88% and freedom from angina was 83%. No patient required repeat percutaneous or surgical intervention. CONCLUSIONS: We conclude that multivessel off-pump revascularization in patients with severe left ventricular dysfunction is a safe and effective alternative to conventional grafting. Long-term follow-up is mandatory to confirm these encouraging intermediate outcomes.     

地尔硫䓬对心肺转流下冠状动脉旁路移植术患者左心室功能的影响

目的探究小剂量地尔硫在心肺转流(CPB)下冠状动脉旁路移植术(CABG)术中应用是否产生抗动脉痉挛作用及左心室负性肌力作用。方法选择择期行CPB下CABG患者43例,男27例,女16例,年龄45~79岁,BMI 18~30 kg/m²,ASAⅡ或Ⅲ级,NYHAⅡ或Ⅲ级,术前左心室射血分数(LVEF)≥45%。随机分为两组:地尔硫组(D组)和对照组(C组),术中均采用全凭静脉麻醉。在置入经食管超声心动图(TEE)探头后,D组静脉输注地尔硫0.5μg·kg^-1·min^-1,C组给予生理盐水,均连续静脉输注至手术结束。在置入TEE探头即刻(T 0)、置入TEE探头后30 min(T₁)、CPB断流20 min(T₂)、50 min(T₃)采用TEE探头采集心脏超声图像,通过斑点追踪技术(STI)离线处理图像,分析并记录左心室功能STI指标:整体纵向应变力(GLS)、整体环向应变力(GCS)、整体纵向达峰时间标准差(GLTSD)、整体环向达峰时间标准差(GCTSD);同时记录传统心功能指标:CI及LVEF;记录左侧乳内动脉桥(LIMA)血流及术后房颤(POAF)发生率、呼吸支持时间、ICU停留时间及总住院时间等术后恢复指标。结果两组不同时点左心室收缩功能及运动同步化指标GLS、GCS、GLTSD、GCTSD差异无统计学意义;两组CI、LVEF差异无统计学意义。D组LIMA血流量高于C组(P<0.05);D组术后6 h cTnI浓度明显低于C组(P<0.05),两组POAF发生率、呼吸支持时间、ICU停留时间及总住院时间差异无统计学意义。结论小剂量地尔硫在CABG术中应用可增加动脉桥血管血流量,同时不产生左心室负性肌力作用。     

Complete revascularization in patients with severe left ventricular dysfunction.

OBJECTIVE: This study evaluates whether patients with coronary artery disease and severely depressed left ventricular ejection fraction (LVEF) benefit from complete revascularization by multivessel coronary artery bypass. METHODS: From April 1994 to May 2002, 42 patients who underwent coronary artery bypass grafting (CABG) at our institution had impaired left ventricular (LV) function [an ejection fraction (EF) of 30% or less]. The average preoperative LVEF was 23.8%. The mean number of grafts was 4.6. Complete revascularization by multivessel bypass grafting was the goal for all patients. RESULTS: Thirty days mortality was 0 and hospital mortality was 2.4%. The mean graft patency rate for 35 (83%) patients at one month was 98.8%. The mean postoperative LVEF improved significantly, from 23.8% to 35.2% (p<0.05), and the New York Heart Association (NYHA) classification was improved in most patients. The Kaplan-Meier estimate of survival at 5 years was 83.1%, and that of the cardiac event-free rate at 5 years was 77.5%. CONCLUSION: For patients with poor LV function, complete surgical revascularization by multivessel bypass grafting can be performed safely, with satisfactory hospital mortality and long-term results.     

Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function.

BACKGROUND: The natural history of aortic valve disease associated with ventricular dysfunction is dismal. Aortic valve replacement (AVR) is associated with increased mortality in patients with left ventricular dysfunction and the long-term outcome in these patients is not well-known. We evaluated perioperative outcomes and long-term results in patients with impaired left ventricular systolic function undergoing AVR. METHODS: Retrospective analysis identified 132 consecutive patients with a left ventricular ejection fraction (LVEF)<40% who underwent AVR with or without concomitant coronary artery bypass grafting (CABG) between 1990 and 2003. Patients with other valve pathology were excluded. RESULTS: Ages ranged from 29 to 94 years (mean 63+/-12), and 117 patients (89%) were male. Preoperatively, 82% were in NYHA III-IV. Sixty patients (45%) underwent AVR for severe aortic stenosis (AS) whilst 72 (55%) had aortic insufficiency (AI). In the AS group, the mean LVEF and aortic valve area were 26+/-4% and 0.8+/-0.4 cm(2), respectively. AI patients had a mean LVEF of 27+/-6% and a mean left ventricular end systolic diameter of 52+/-9 mm. Fifty-seven (43%) required concomitant CABG. There were only three perioperative deaths (2.3%) and no strokes. One patient (0.8%) had postoperative renal failure, and one suffered a myocardial infarct. Nine patients (6.9%) required a postoperative IABP. LVEF increased to 29+/-10% and 34+/-12% after six months in the AS and AI groups, respectively. The mean follow-up period was 6.1 years and no differences between the AS and AI groups were observed with respect to either perioperative or long-term outcomes. Overall survival was 96%, 79% and 55% at 1, 5 and 10 years, respectively. CONCLUSIONS: The long asymptomatic course of AS and AI means that many patients have impaired ventricular function at diagnosis. This study demonstrates that AVR in such patients can be performed with low perioperative morbidity and mortality. The outlook after surgery is excellent. A 10-year-survival of 55% compares favourably with heart transplantation and particularly with medical therapy. AVR is a safe, effective and durable option, which should not be denied to patients on the basis of low LVEF alone.     

Tolerance to ACE inhibitors after cardiac surgery.

OBJECTIVES: Several studies have shown angiotensin-converting enzyme (ACE) inhibitors to confer significant mortality and morbidity benefits in heart failure. First-dose hypotension may necessitate interruption of such therapy. This is more likely to occur if the ACE inhibitor is administered early after coronary artery bypass grafting (CABG). The purpose of this study was to analyse the haemodynamic tolerance to early post-operative treatment with perindopril and enalapril in patients with impaired renal and ventricular function. METHODS: Eighty one consecutive CABG patients with a previous myocardial infarction, impaired pre-operative left ventricular ejection fraction (LVEF) on ventriculography and moderately impaired renal function (serum creatinine of 115-150 micromol/l) were randomised into three groups to receive oral placebo, perindopril (4 mg) or enalapril (5 mg) once daily. Groups were subdivided into those with mild ventricular dysfunction (LVEF = 35-65%, n = 20) and significant ventricular dysfunction (LVEF < 35%, n = 7). Exclusion criteria included oliguria (<0.5 ml/kg per h) or inotrope dependance at the point of entry on the first post-operative day. Intolerance to ACE inhibitor was defined as hypotension (<95 mmHg systolic blood pressure or a decrease exceeding 25 mmHg in systolic blood pressure) leading to oliguria (<0.5 ml/kg per h) which was unresponsive to intravenous furosemide (20 mg). In such cases ACE inhibitor treatment was discontinued and patients commenced on dopamine. RESULTS: In the groups with mild ventricular dysfunction (LVEF = 35-65%) perindopril was discontinued in 1/20 and enalapril in 4/20 patients (P = n.s). However, in the groups with significant ventricular dysfunction (LVEF < 35%) perindopril was discontinued in 2/7 and enalapril in 7/7 patients (P = 0.02). CONCLUSION: Our results suggest that after CABG, patients with moderately impaired renal function and significant ventricular dysfunction do not tolerate ACE inhibitors well when these were commenced on the first post-operative day. However, perindopril was associated with less haemodynamic deterioration than enalapril and consequently may be advantageous in this setting. rights reserved.     

非体外循环和体外循环冠状动脉旁路移植术在二次冠状动脉旁路移植术中的应用

目的研究对比在二次冠状动脉旁路移植术(re-CABG)患者中分别采用非体外循环和体外循环下冠状动脉旁路移植术(off-pump CABG和on-pump CABG)的临床早期结果,探讨通过合理手术方式的选择,提高re-CABG的手术疗效。方法自2000年4月到2006年6月,21例首次CABG后因心绞痛复发患者在阜外心血管病医院接受了re-CABG手术,其中10例行off-pump CABG(off-pump组),11例行on-pump CABG(on-pump组)。两组患者术前性别、年龄、体重、心肺功能、心绞痛程度、左心室舒张期末内径、射血分数、合并高血压、糖尿病等方面差异无统计学意义(P>0.05)。结果 On-pump组中患者术后死亡1例,冠状动脉远端吻合口数多于off-pump组(P<0.05);off-pump组无手术死亡,在手术时间、术后呼吸机辅助时间、胸腔引流液量、输血量和手术后住院时间等方面,均明显少于on-pump组(P<0.05)。结论 Off-pump CABG和on-pump CABG技术在re-CABG中都可以取得满意疗效,off-pump CABG下施行re-CABG安全可靠。     

Right ventricular function: a comparison between blood and crystalloid cardioplegia

Blood cardioplegia resulted in better left ventricular (LV) function than crystalloid cardioplegia after elective coronary artery bypass operations. However, most methods of cardioplegic delivery may not adequately cool and protect the right ventricle, and right ventricular (RV) dysfunction may limit hemodynamic recovery. Therefore, RV and LV temperatures were measured intraoperatively and RV and LV function were evaluated postoperatively in 80 patients with double-vessel or triple-vessel coronary artery disease who were randomized to receive either blood cardioplegia or crystalloid cardioplegia. Myocardial performance, systolic function, and diastolic function were assessed with nuclear ventriculography by evaluating the response to volume loading. Preoperatively the groups were similar. Intraoperatively, blood cardioplegia resulted in significantly warmer LV and RV temperatures (left ventricle: 15.5 degrees +/- 0.2 degrees C with blood cardioplegia and 12.6 degrees +/- 0.3 degrees C with crystalloid cardioplegia [p less than .0001]; right ventricle: 18.3 degrees +/- 0.3 degrees C with blood cardioplegia and 15.1 degrees +/- 0.3 degrees C with crystalloid cardioplegia [p less than .0001]). Postoperatively, blood cardioplegia resulted in better LV performance (higher LV stroke work index at a similar LV end-diastolic volume index [EDVI]) (p = .01), better LV systolic function (similar systolic blood pressures at smaller LV end-systolic volume indexes [ESVI]), (p = .04), and improved LV diastolic function (lower left atrial pressures at similar LVEDVIs) (p = .03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy of additional Dor approach to coronary bypass grafting in severe left ventricular dysfunction with large akinetic area

Between January 1994 and August 1999, we experienced 16 cases of coronary artery bypass grafting (CABG) in severe left ventricular dysfunction with left ventricular ejection fraction (LVEF) < or = 40%. Four had additional endoventricular patch plasty in large postinfarction akinetic scars, the so-called Dor approach, to CABG (group D). Eleven had only CABG, or CABG and mitral annuloplasty (group C). One had linear repair after the resection of the left ventricular aneurysm. One died of sustained low output syndrome 5 months after the operation in group C. Fractioning shortening and left ventricular diastolic diameter were not changed after the operation in group C. On the other hand, in group D, there were no complications after the operation, LVEF was significantly improved from 31.5 +/- 4.9% to 62.5 +/- 5.9% (p < 0.01) and the left ventricular end-diastolic volume index was reduced from 118 +/- 23 ml/m2 to 74 +/- 12 ml/m2 (p < 0.01). The Dor approach is considered to be a safe and effective additional procedure to CABG in severe patients with a large akinetic antero-septal segment.     

Outcome of geometric endoventricular repair in impaired left ventricular function

BACKGROUND: Traditionally, repair of left ventricular aneurysms has been limited to patients with large localized ventricular aneurysms. Repair of dyskinetic segments in the setting of poor left ventricular function is still contentious. METHODS: Forty patients underwent geometric endoventricular repair, a new technique of ventricular aneurysm repair, over a 2-year period. Two groups of patients undergoing coronary artery bypass grafting (CABG) for left ventricular dysfunction in the same time period were reviewed. Group 1 comprised 23 consecutive patients who underwent geometric endo-ventricular repair along with CABGs, whereas group II consisted of 22 patients who underwent CABG alone. RESULTS: The early mortality was 9.1% in group I (1 cardiac, 1 noncardiac) and 0 in group II (NS). New York Heart Association class was remarkably improved from 3.4 to 1.4 (p < 0.05) in group I and to a lesser extent in group II (3.7+/-0.5 versus 2.3+/-0.5). Diastolic dimension of left ventricle was significantly reduced from 5.6 cm to 4.4 cm (p < 0.05) in group I and virtually unchanged in group II. There was one late death in each of the groups. CONCLUSIONS: This technique of geometric left ventricular aneurysm repair is useful in patients with dyskinetic segments and may help in reducing cardiac size.     

Late Results with Concomitant Coronary Artery Bypass Grafting and ICD Implantation

A bstract Background : To determine the influence of left ventricular function on the long-term survival of patients with coronary artery disease and lethal ventricular arrhythmias, who undergo concomitant coronary artery bypass grafting (CABG) and implantable cardiovertor defibrillator (ICD) implantation, we studied survival in 54 consecutive patients who underwent CABG and ICD implantation. Methods : Group I consisted of 35 patients with left ventricular ejection fraction (LVEF) ± 35% (mean 25.3 ± 5.6) and Group II consisted of 19 patients with LVEF > 35% (mean 47.5 ± 6.6). The two groups were similar with regards to age, gender, clinical presentation, induced arrhythmias, and the number of grafts placed at the time of surgery. Results: Two in-hospital deaths (3.7%) occurred, both in Group I. During follow-up (42.5 ± 21.8 months), there were 10 deaths in Group I (1 noncardiac, 1 sudden, and 8 heart failure), and 1 death in Group II (heart failure) (p < 0.04). Conclusions : Concomitant CABG and ICD implantation can be performed with an acceptable in-hospital mortality, even in patients with poor left ventricular function. Although freedom from sudden cardiac death remains excellent, overall long-term survival is limited by refractory heart failure, especially in those patients with left ventricular dysfunction at the time of surgery.     

Surgical treatment of aortic arch aneurysm combined with coronary artery stenosis.

OBJECTIVE: We present operative results of aortic arch aneurysm associated with coronary artery stenosis, and evaluate the operative risk of graft replacement of the aortic arch and concomitant coronary artery bypass grafting (CABG). PATIENTS AND METHODS: From January 1991 to December 2001, we treated 16 patients with aortic arch aneurysm and coronary artery stenosis. The patients, 3 women and 13 men (study group) ranged from 58 to 79 years of age, average 68.1 5.3 years. With the aid of deep hypothermic cardiopulmonary bypass, we performed graft replacement of the aortic arch aneurysm and concomitant CABG. We bypassed 31 coronary arteries. The bypass grafts included saphenous vein (n=16), left internal thoracic artery (n=4), right internal thoracic artery (n=1), right gastroepiploic artery (n=5) and inferior epigastric artery (n=2). The number of bypassed coronary arteries per patient ranged from 1 to 3, average 2.1 0.8/patient. A comparative study was performed between the study group and a control group of patients (n=39) who had undergone only graft replacement of the aortic arch. RESULTS: There was no significant difference between the two groups regarding: operation time, cardiopulmonary bypass time, cardiac arrest time, intraoperative bleeding volume, and early mortality rate. However, in the patients (n=4) of the study group who had undergone total arch graft replacement with three vessel CABG, the cardiopulmonary bypass time was significantly longer than that of the patients in the control group who underwent total arch graft replacement (n=19, P<0.05). Two of the 16 study group patients died in the early postoperative period, resulting in 12.5% early mortality rate. In the control group, four of 39 patients (10.3%) died in the early postoperative period. CONCLUSIONS: CABG combined with graft replacement of the aortic arch does not increase operative risk when the number of bypassed vessels is within two vessels, but may increase risk when three or more vessels are bypassed.     

常规与非体外循环冠状动脉旁路移植术炎症因子比较

目的：比较多支冠状动脉（冠脉）病变行常规体外循环冠状动脉旁路移植术（CABG）和非体外循环冠状动脉旁路移植术（OPCAB）围术期心肌损伤和炎症因子的变化情况。方法：CABG组（A组，13例），OPCAB组（B组，22例）。分别于麻醉诱导后、手术结束后即刻、术后24h和48h进行血样检测，分别测定TNF－α、IL-1β、IL-8和IL－10水平。另外记录围手术期各项临床指标如引流量、输血量、呼吸机使用时间和发热时间等。结果：两组在年龄、冠脉病变程度、心功能和血管旁路移植数目上相似。术后IL－8水平OPCAB组相对稍高，但两组无显著差异。围术期CABG组IL－1、TNF较OPCAB明显为高（P＜0．05）。但炎症因子IL－10 OPCAB组却较CABG组明显升高（P＜0．05），术后24h达高峰。最后，CABG较OPCAB病人呼吸机使用时间延长且发热时间延长。结论：与CABG组相比，OPCAB组围术期炎症反应和术后并发发症明显降低。     

Oral thyroid hormone pretreatment in left ventricular dysfunction.

OBJECTIVE: The aim of the present study was to determine whether pretreatment with oral thyroid hormone had beneficial effects in cardiac function and morbidity and mortality after cardiac operations. METHODS: Eighty patients undergoing coronary artery bypass grafting with a preoperative left ventricular ejection fraction (LVEF) less than 30% scheduled for elective coronary bypass grafting agreed to participate in this prospective, randomized trial. The triiodothyronine (T(3)) (Group I) and control groups (Group II) were equally divided. Patients randomized to the T(3) group received T(3) 125 microg/day orally for 7 days preoperatively and from the first postoperative day till the discharge. Outcome variables included perioperative hemodynamic data, inotropic requirements, morbidity and mortality. Hemodynamic data were collected before induction of anesthesia and following every 4 h. The thyroid profile was determined upon admission, after the induction of anesthesia, 5 min after the start of cardiopulmonary bypass (CPB) and after hourly intervals and after 24th hour, at 24h intervals till the 120th hour. RESULTS: There were 6 deaths, three in each group. Patients in the T(3) group demonstrated a higher cardiac index than patients in the placebo group in the entire post-CPB periods (P<0.01). Mean inotropic requirements remained lower in the T(3) group than in the placebo group (P<0.001). CONCLUSIONS: Although our study stresses the benefits of oral T(3) administration on the hemodynamic and prognostic parameters in patients with impaired left ventricular function and undergoing CABG weakly, it may warrant further much larger scaled studies that can reach statistical significance.     

Results of coronary artery bypass grafting alone and combined with surgical ventricular reconstruction for ischemic heart failure

In this study, we included 236 patients with ischemic heart failure and ejection fraction (EF) <35% who underwent surgical treatment. Patients were randomized in two groups. There were 116 patients who underwent coronary artery bypass grafting (CABG) with surgical ventricular reconstruction (SVR) and 120 patients who underwent CABG alone. The hospital mortality rate was 5.8% after isolated CABG and 3.5% after CABG combined with SVR. All survivors had follow-up investigation from four months to five years, with a mean follow-up time of 31±13 months. The mean New York Heart Association (NYHA) functional class decreased from 2.9±0.5 to 2.2±0.7 one year after CABG and from 3.1±0.4 to 2.0±0.6 one year after CABG with SVR. We showed that left ventricular reconstruction significantly decreased EDV from 237±52 to 176±30 and correspondingly increased EF from 32±6 to 39±9. However, after isolated CABG EF did not increase significantly (32±7 preoperatively and 34±11 postoperatively). One- and three-year rates were 95% and 78% after SVR with CABG and 83% and 78% after CABG alone. Despite the more aggressive surgical strategy, left ventricular reconstruction did not increase operative mortality and early results were significantly effective compared with coronary artery bypass grafting alone.     

Does off‐pump coronary artery bypass grafting beneficially affect renal function?

BACKGROUND: Off-pump coronary artery bypass grafting (CABG) has been reported to beneficially affect renal function, but this remains to be confirmed. The purpose of the present paper was to study the effects of off-pump CABG on renal function and analyse predictors of postoperative renal impairment in patients who received off-pump CABG. METHODS: A total of 451 patients who underwent isolated CABG between January 1999 and August 2003 were retrospectively studied. No patient was receiving dialysis. A total of 300 patients (228 men) underwent off-pump CABG (off-pump group) and 151 patients (104 men) underwent on-pump CABG (on-pump group). Perioperative serum creatinine levels and creatinine ratios (peak postoperative creatinine level/preoperative creatinine level) were compared between the groups. RESULTS: Renal impairment (serum creatinine >1.5 mg/dL) developed postoperatively in 12.7% of the off-pump group and 18.5% of the on-pump group (P = 0.1). The creatinine ratio was significantly lower in the off-pump group (1.2 +/- 0.4) than in the on-pump group (1.4 +/- 0.7, P = 0.003). Logistic regression analysis demonstrated that the strongest predictors of postoperative renal impairment in off-pump CABG were left ventricular dysfunction (odds ratio 10.8) and multivessel grafting (odds ratio 4.3). CONCLUSIONS: Off-pump CABG provides better renal protection than on-pump CABG. However, perioperative renal function should be closely monitored in patients who have left ventricular dysfunction or who undergo multivessel grafting, even when off-pump CABG is performed.