Spinal infarction following coronary artery bypass grafting

Spinal infarction is an extremely rare complication of coronary artery bypass grafting (CABG), almost invariably associated with use of the intra-aortic balloon pump (IABP). We present the case of a 63-year-old lady who developed paraplegia, secondary to spinal infarction, following CABG in whom the IABP was not used and no other predisposing factors were present.     

Breast infarction due to calciphylaxis after coronary artery bypass grafting

The use of the internal mammary artery for coronary artery bypass grafting is common. We describe a patient with chronic renal insufficiency who had no need for dialysis, and who suffered from breast necrosis after coronary artery bypass grafting with internal mammary artery harvesting due to calciphylaxis. The histology report of the breast tissue showed mural vascular calcification and intima proliferation of small-sized to medium-sized vessels. This causes ischemic necrosis of the skin and septal panniculitis. We believe that this is the first case report of breast necrosis after coronary artery bypass grafting, due to calciphylaxis in a patient with known chronic renal insufficiency, without renal replacement therapy.     

Predictors of inotropic support during weaning from cardiopulmonary bypass in coronary artery bypass grafting surgery

Early or prophylactic inotropic drug administration is occasionally required to facilitate separation from cardiopulmonary bypass (CPB) in cardiac surgery. However, it is not without untoward effects and should be conducted on the basis of rational criteria. The purpose of our study was to clarify variables associated with the requirement for inotropic support during separation from CPB and to testify whether pre-CPB left ventricular (LV) function, as evaluated by transesophageal echocardiography (TEE), is one of the significant variables. Clinical profile data and TEE findings were retrospectively analyzed for 91 patients who had received elective primary isolated coronary artery bypass grafting (CABG) surgery. Post-CPB inotropic drug administration initiated prior to aortic decannulation was considered inotropic support for terminating CPB. Stepwise multiple logistic regression analysis identified pre-CPB LV regional wall motion abnormalities (RWMA), NYHA class, age, and duration of CPB (in order of significance) as factors associated with inotropic support for discontinuing CPB. Pre-CPB LV enddiastolic area or fractional area change was not a significant variable in the multivariate model. Our result suggests that evaluation of pre-CPB LV RWMA is useful in predicting the need of inotropic intervention during separation from CPB in patients undergoing CABG surgery. This study was performed at The Weiler Hospital of The Albert Einstein College of Medicine, and was presented in part at the 17th annual meeting of The Society of Cardiovascular Anesthesiologists, Philadelphia, Pennsylvania, May 8–10, 1995     

Successful emergency coronary artery bypass grafting after use of a percutaneous cardiopulmonary support system in a patient with cardiopulmonary arrest secondary to acute myocardial infarction

A 37-year-old woman was taken to a hospital because of sudden chest pain. She lapsed into shock, and the ECG indicated acute myocardial infarction. The ECG later showed ventricular fibrillation, and the patient was given cardiac massage while being transported to our hospital, where she was resuscitated with a percutaneous cardiopulmonary support system. Emergency coronary angiography revealed 99% stenosis of the left main coronary artery. PTC A was performed, and the stenotic lesion was released, but dissection and rapid formation of a thrombus were detected in the LAD. Re-PTCA was performed, but the hemodynamics did not improve, and emergency CABG of the LAD, Dl, and LCx was performed. Postoperative max CPK was 18,957 IU/L. Although postoperative MRSA pneumonia developed as a complication, weaning from the respirator was performed 17 days after the operation. The patient was discharged, ambulatory, 74 days after the operation.     

Reoperative coronary artery bypass grafting without cardiopulmonary bypass

Between October 1995 and Feburary 1997, 2 men and 4 women aged 53 to 75 years (mean, 66.3) underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated reoperative circumflex or intermediate artery bypass was performed through a left thoracotomy (n=2), reoperative bypass to the left anterior descending coronary aretery was performed through a median sternotomy (n=3), and bypass to the right coronary artery was performed through an upper median laparotomy (n=1). Single coronary bypass grafting utilizing arterial grafts (left internal thoracic artery: 3, right gastroepiploic artery: 3) was performed in all cases. There were no operative deaths. All cases required neither cathecolamine nor intraaortic balloon pumping). Peri/post operative blood transfusion was necessary in only one case. Postoperative coronary angiography revealed that the 6 arterial grafts were patent. Reoperative coronary artery bypass grafting without cardiopulmonary bypass can be performed with low perioperative morbidity and mortality, easy postoperative management, satisfactory graft patency, and good symptomatic improvement.     

Fatal fungal infection complicating aortic dissection following coronary artery bypass grafting

The case of a 52-year-old man with severe coronary atheroma/ischaemic heart disease, who underwent successful triple vessel coronary artery bypass grafting is described. One month later this was complicated by aortic dissection arising at the aortic cannulation site. An emergency resection and Dacron graft placement were performed. Five weeks later he represented with haemoptysis. Despite inconclusive investigations the patient went on to suffer a massive fatal haemoptysis. Autopsy revealed Candida infection of the graft with a secondary aortobronchial fistula.     

A case of successful emergency coronary artery bypass grafting surgery for failed coronary angioplasty using percutaneous cardiopulmonary support]

This is the first Japanese case of the successful emergency coronary artery bypass grafting (CABG) surgery for failed percutaneous transluminal coronary angioplasty (PTCA) using percutaneous cardiopulmonary support (PCPS). A 81-year-old woman with old myocardial infarction and angina pectoris is presented. Her coronary angiogram showed the 90% and 50% stenosis of the right coronary artery (RCA) and the total occlusion of the left anterior descending artery (LAD). PTCA for the 90% stenosis of RCA was performed. But, during the balloon dilation, her heart rate and blood pressure decreased. PTCA was stopped. As her chest pain was worse, re-PTCA was tried, using PCPS. Under PCPS (3 l/min), the balloon dilation was performed safely and smoothly. But, the unexpected dissection of RCA occurred, and became larger rapidly. After 85 minutes, the emergency CABG was performed. By using PCPS, the stable hemodynamics was given till the operation. CABG to RCA and LAD was performed safely. After the surgery, the patient progressed well. PCPS was a very useful cardiopulmonary assist device.     

Emergent coronary artery bypass grafting using percutaneous cardiopulmonary support in a patient with a quadricuspid aortic valve; report of a case

A 63-year-old man was admitted to our hospital for acute myocardial infarction. A cardiac catheter study showed 3 vessels coronary disease. He was treated by percutaneous coronary intervention for a left anterior descending arterial (LAD) lesion. Unfortunately, cardiac tamponade following stenting for LAD was complicated. A percutaneous cardiopulmonary support system was commenced along with an emergent coronary artery bypass grafting to the LAD and obtuse marginal branch. A quadricuspid aortic valve was discovered by an aortotomy and identified as Hurwitz-Roberts classification type b. Blood from the left coronary main trunk had already stopped. Intraaortic balloon pumping was instituted while weaning from the cardiopulmonary bypass. The patient's postoperative course was uneventful and all bypass grafts were sufficient. He was well 1 year after the operation.     

Ultrasonic evaluation of graft anastomoses during coronary artery bypass grafting without cardiopulmonary bypass

Performance of the graft-to-coronary anastomosis in coronary artery bypass grafting without cardiopulmonary bypass is more difficult than conventional coronary artery bypass grafting. We report a new method that uses high-frequency epicardial echocardiography to detect technical errors and inadequacies in graft anastomoses. This method improves the operative outcome and enables detection of septal perforator branches and deeply embedded coronary arteries during coronary artery bypass grafting without cardiopulmonary bypass.     

Heart rate reduction using edrophonium during coronary artery bypass grafting without cardiopulmonary bypass

Coronary artery bypass grafting without the use of cardiopulmonary bypass (CPB) is performed with increasing frequency. Performing revascularization on a beating heart is technically more demanding than performing revascularization on the arrested heart, especially in high-risk patients. beta-Blockers and calcium-channel antagonists have been used for the reduction of heart rate (HR) for the local immobilization of the anastomotic site. However, their negative inotropic actions often lead to serious hypotension. Therefore, we investigated the effect of edrophonium on HR reduction in high-risk patients undergoing CABG without CPB. Ten high-risk patients undergoing CABG without CPB were selected. To reduce HR during anastomosis, edrophonium was administered during the procedure. Systemic blood pressure (sBP), HR, and cardiac index (CI) were measured from the induction of anesthesia to the end of surgery. All surgeries were successfully performed without serious complications. To keep the rate under 60 bpm, edrophonium was administered at the time of anastomosis and this decreased the cardiac index from 2.19 to 1.95, while the sPB was maintained easily over 90 mmHg with the infusion of methoxamine. Edrophonium may be useful for the reduction of HR during coronary anastomosis in high-risk patients undergoing CABG without CPB.     

Prompt institution of percutaneous cardiopulmonary support managed perioperative refractory vascular spasm after isolated coronary artery bypass grafting surgery

A 51-year-old Japanese male underwent on-pump coronary artery bypass grafting surgery. After weaning from cardiopulmonary bypass (348 min), sudden bradycardia and hypotension occurred, followed by ventricular fibrillation. Although defibrillation and infusion of catecholamine restored sinus rhythm, transesophageal echocardiography demonstrated severely reduced contraction of both ventricles, and perioperative vascular spasm was suspected. As vascular spasm was refractory to medications, percutaneous cardiopulmonary support (PCPS) system was quickly instituted under cardiac massage. Coronary angiography revealed vascular spasm of not only the native coronary arteries but also the implanted left internal thoracic artery. After 3 days of full hemodynamic assist, PCPS was withdrawn with no obvious abnormalities in regional wall motion by transesophageal echocardiography. The patient was extubated on postoperative day 6 with no impaired brain function. In this case, the immediate diagnosis of refractory vascular spasm by transesophageal echocardiography and full cardiocirculatory assistance by PCPS helped to save the life of the patient.     

Diagnosis of an intraoperative aortic dissection by transesophageal echocardiography during routine coronary artery bypass grafting surgery

Acute aortic dissection during coronary artery bypass grafting (CABG), though rare, causes significant morbidity and mortality. We report a case of postcardiopulmonary bypass aortic dissection in a 73-yr-old man who presented for CABG. The diagnosis was made by transesophageal echocardiography and allowed immediate treatment of the potentially lethal complication. IMPLICATIONS: Acute aortic dissection during coronary artery bypass grafting (CABG), though rare causes frequent morbidity and mortality. We report a case of postcardiopulmonary bypass aortic dissection in a 73-yr-old man who presented for CABG. Diagnosis made by transesophageal echocardiography allowed immediate treatment of the potentially lethal complication.     

Is coronary artery bypass grafting without cardiopulmonary bypass safe?

Summary Three hundred and fifty patients underwent coronary artery bypass surgery on a beating heart. This technique is easy to learn and is suitable in selected patients.     

Neuronal and astroglial injuries in patients undergoing coronary artery bypass grafting and aortic arch replacement during hypothermic cardiopulmonary bypass

More than 50% of patients suffer neuropsychologic impairment after cardiac surgery. We measured neuron-specific enolase (NSE) and S-100 protein (S-100) in patients' serum as putative markers of neuronal and astroglial cell injury, respectively. Group I (n = 13) underwent coronary artery bypass grafting (CABG) with mild hypothermic cardiopulmonary bypass (CPB); Group II (n = 6) underwent aortic arch replacement with deep hypothermic CPB; Group III (n = 8) underwent CABG under normothermia without CPB. During and after the operation, serum levels of NSE and S-100 were significantly increased only in Groups I and II (during CPB), NSE still being increased 12 h after surgery in Group II. This suggests that neuronal and astroglial cell injuries are more likely in patients undergoing CABG with mild hypothermic CPB or aortic arch replacement with deep hypothermic CPB than in those undergoing CABG under normothermia without CPB. However, these increases of NSE and S-100 failed to reflect clinical brain damage. Rather, an electroencephalogram, was only capable of detecting neurologic complications after surgery. Implications: Neuronal and astroglial cell injuries are likely to occur during coronary artery bypass grafting with mild hypothermic cardiopulmonary bypass (CPB) or aortic arch replacement with deep hypothermic CPB. Conversely, patients undergoing coronary artery bypass grafting without CPB under normothermic conditions may be less likely to suffer brain cell injury.     

Aortic dissection after previous coronary artery bypass grafting

Aortic dissection after coronary artery bypass grafting (CABG) is a rare but potentially fatal complication. The aim of this study was to identify the reasons. Between 1991 and 2000 in our institution CABG was performed on 22,732 patients. In the same time interval 12 (0.5 degree/00) patients presented with an aortic dissection after previous CABG. Age: 59.1 +/- 5.9 years, gender: 10/2, only Stanford A dissections, 4 chronic and 8 acute dissections, mortality: 3, all acute. 2 died of cardiac complications (left heart failure), 1 of other complications (gastrointestinal ischemia). The time interval between CABG and dissection was 2.5 +/- 3.6 years. Two dissections were intraoperative, another 5 were within the first year; the longest time interval was 10 years. In 5 cases the entry originated from a central anastomosis, 1 originated from the aortic cannulation site, and 1 from the site of the cross clamping. In 5 cases the entry was not directly related to the previous operation (1 was located in close proximity to the left coronary ostium, 2 between aortic valve annulus and the coronary ostia and 2 between the distal coronary arteries in the ascending aorta). Pathological changes of the aorta were not described at the time of CABG; only in 1 case a mild aortic regurgitation and dilatation (47 mm) at the time of the first operation was described. As our results suggest an aortic dissection presenting after CABG must be considered to be a rare complication of the previous operation. Considering the severity of this complication satisfying results can be achieved.     

Anesthetic management of cardiac pheochromocytoma resection and coronary artery bypass grafting under cardiopulmonary bypass

We experienced pheochromocytoma resection and coronary artery bypass grafting under cardiopulmonary bypass (CPB). The patient was a 69-year-old man who was first diagnosed with atherosclerotic angina. During operation, his blood pressure increased at induction and manipulation of the tumor under CPB, associated with an increased serum noradrenaline concentration. Starting operation, we monitored using transesophageal echocardiography (TEE), and used that view for diagnosis and anesthetic or hemodynamic management. It was especially useful after tumor resection. Surgical and hemodynamic management was facilitated by TEE. TEE was useful to make a diagnosis of cardiac pheochromocytoma, to determine the area of resection, to determine the surgical repair, and to make a decision of hemodynamic management in this complicated patient. We suggest that perfoming these cases under CPB and TEE is recommended for stabilization of hemodynamic states.     

Peripheral blood monocyte activation during coronary artery bypass grafting with or without cardiopulmonary bypass

Objective. The aim of this prospective, randomized study was to investigate the impact of coronary artery bypass grafting (CABG) on peripheral monocytes and to evaluate the additional effect of cardiopulmonary bypass (CPB).

Design. Twenty patients admitted for elective CABG were randomized to either on-pump (ONCAB, n=9) or off-pump (OFFCAB, n=11) surgery and blood samples were drawn before, during and 24 h after the operation. The total number of monocytes and the proportion of the more mature CD16⁺/CD14⁺ monocytes were measured. Expression of activation markers (CD11b, CD35 and CD62L) and oxidative burst were determined using flow cytometry on both resting and in vitro stimulated cells. Serum concentrations of soluble CD14 and monocytes/macrophage chemotactic protein 1 (MCP-1) were analysed.

Results. During surgery there was a selective decrease in the proportion of CD16⁺/CD14⁺ monocytes compared to total monocytes. These had returned to preoperative values 24 h after surgery while the total number of monocytes had increased more than 100%. Intracellular production of oxygen free radical H₂O₂ was increased in the ONCAB group during surgery compared to OFFCAB. Monocyte expression and in vitro mobilization of complement receptors, CD11b and CD35, were similar in both study groups during and after surgery as was the expression of CD62L. Serum levels of MCP-1 decreased during surgery as did soluble CD14, both with increased levels again the day after surgery.

Conclusion. It is concluded that the circulating monocyte population is activated during and as a consequence of CABG. There were few apparent additional effects of CPB found in this study. In this setting the inflammation caused by the surgery procedure per se probably surpasses the impact of the CPB on circulating blood monocytes.