Reoperative coronary artery bypass grafting without cardiopulmonary bypass.

Conventional reoperative coronary artery bypass grafting (CABG) is associated with increased surgical risk. The use of less invasive methods to perform myocardial revascularization may, therefore, be more suitable, especially for high-risk patients. In June 1999, we performed three reoperative CABG surgeries, without the use of cardiopulmonary bypass, through unilateral or bilateral thoracotomy. One patient had single-vessel disease and the other two had multiple-vessel disease. All three patients had uneventful postoperative recovery. During early postoperative follow-up, all three patients were angina-free and were in New York Heart Association functional class I. The results of these three cases suggest that minimally invasive reoperative CABG may reduce morbidity compared with conventional reoperative CABG.     

Endoscopic radial artery harvest for coronary artery bypass surgery.

BACKGROUND/PURPOSE: Coronary artery bypass grafting (CABG) provides better long-term patency than percutaneous intervention in patients with significant coronary artery disease. The radial artery is the second most common arterial conduit used for CABG in Western countries. However, radial artery harvesting necessitates a large surgical wound and has gained few patients' acceptance in subtropical areas. This study investigated the use of the minimally invasive approach of endoscopic radial artery harvest for CABG, and the surgical results at the harvest site. METHODS: An endoscopic harvest program for radial arteries was implemented in this hospital in September 2003. During the first 12 months of the program until September 2004, 122 patients underwent the procedure. Preoperative evaluation included Allen's test and the modified palmar arch perfusion test. The age of patients ranged from 32 to 88 years old. Patients were excluded from participation if they had undergone recent transradial catheterization, had end-stage renal disease or documented peripheral artery occlusive disease. The VasoView system was utilized for the procedure. Details of the surgical techniques used were recorded and analyzed. RESULTS: Using the endoscopic technique, 122 radial arteries were harvested successfully. The mean resting length of the harvested radial artery was 15.7 cm. No obvious arterial injury was visually confirmed. All radial arteries were used for CABG, except for two which were noted to have atherosclerotic plaques causing stenoses. Forty-seven patients presented with mild numbness over the dorsum of the thumb base, which improved significantly during the 3-month follow-up. No arterial insufficiency in the forearms or hands was noted. CONCLUSION: Endoscopic harvest of the radial artery is technically demanding, but excellent results can be achieved. The endoscopic approach can provide suitable conduits in a less invasive way than the open harvest technique.     

Comparison of outcome of off-pump coronary artery bypass surgery and conventional coronary artery bypass surgery.

BACKGROUND AND PURPOSE: Off-pump coronary artery bypass grafting (CABG) [OPCAB] is preferred to conventional CABG with cardiopulmonary bypass (CPB) for many specific subgroups, such as elderly patients and high-risk patients. Whether OPCAB should be the first choice of surgical procedure for a wider range of coronary artery disease patient subgroups remains controversial. The purpose of this study was to compare the clinical results of OPCAB and CPB in our hospital. METHODS: We retrospectively analyzed the results for 404 patients who received OPCAB or CPB between March 2000 and December 2001. Surgical methods adopted were at the discretion of the attending surgeon. In addition, subgroups of patients were analyzed to assess whether or not OPCAB was more successful in patients with specific characteristics. RESULTS: There were no significant differences in the demographic data between the 2 groups. The perioperative mortality rate was similar for the CPB and OPCAB groups (2.5% and 2.0%, respectively; p = 1.00.) OPCAB was superior with respect to inotropic use, postoperative bleeding amount, transfusion amount, and length of intensive care unit and hospital stay (p < 0.05 for all), and also had a lower incidence of re-entry due to bleeding (6.7% vs 13.6%, p = 0.04) and prolonged hospitalization > 30 days (1.5% vs 10.8%, p < 0.01). At 12 months' follow-up, the OPCAB group had a lower rate of mortality (1.5% vs 5.6%, p = 0.03) and a comparable rate of readmission for cardiac reasons (6.6% vs 9.6%, p = 0.28). The rate of poor in-hospital outcome was lower in the OPCAB than in the CPB group (3.0% vs 13.3%, p 65 years, age < 65 years, diabetes, peripheral arterial occlusive disease, end-stage renal disease, left ventricular ejection fraction < 50%, preoperative intra-aortic balloon pump use, and left-main disease had better in-hospital outcome in the OPCAB group compared with the CPB group, while no subgroups had worse in-hospital outcomes with OPCAB. The 12-month follow-up outcome was similar with the 2 techniques. CONCLUSION: Use of OPCAB in CABG operation was associated with improved in-hospital outcome and similar follow-up outcome compared to CPB. No subgroup had a worse outcome with OPCAB.     

非体外循环下冠状动脉搭桥30例术后护理体会

目的:探讨非体外循环下冠状动脉搭桥(OPCAB)术后临床护理。方法:对30例患者术后进行心电监护、血流动力学监测、呼吸功能、肾功能的监测等处理措施,同时进行抗凝处理及并发症的观察与护理。结果:术后心绞痛症状均缓解,心功能明显改善,经住院1 5d全部康复出院。结论:OPCAB手术后的心血管专科护理能促进患者尽快康复,对OPCAB的疗效提高发挥不容忽视的作用。     

Estrogen therapy in women undergoing coronary artery bypass grafting: effect on surgical complications

OBJECTIVE: To determine whether estrogen therapy at the time of coronary artery bypass grafting affects postoperative complications. METHODS: Consecutive postmenopausal women who had coronary artery bypass grafting between 1992 and 1997 were identified and their medical records were reviewed. Outcome measures included mortality, perioperative cardiac morbidity, and early and late postoperative complications. RESULTS: Estrogen therapy was noted in 13.9% of 734 women. Those using estrogen replacement were younger (63.9 +/- 0.27 versus 68.8 +/- 0.64 years) and had higher ejection fractions (2.8 +/- 0.11 versus 3.1 +/- 0.04) and fewer vessels bypassed. Mortality rates were 2.9% for estrogen users and 7.4% for nonusers (odds ratio [OR] 0.38; confidence interval [CI] 0.07, 1.21). Perioperative cardiac morbidity rates were 5.8% for estrogen users and 11% for nonusers (OR 0.52; CI 0.23, 1.7). Early complication rates were 0. 98% for estrogen users and 1.11% for nonusers. Late inpatient complications were noted in 6.8% of treated women and 14.8% of those untreated (OR 0.42; CI 0.16, 0.96). Stepwise logistic regression confirmed age, New York Heart Association angina classification, and ejection fraction as significant variables for mortality, perioperative cardiac morbidity, and late complications. Estrogen therapy did not influence mortality, perioperative cardiac morbidity, or early or late complications. CONCLUSION: Age, ejection fraction, and New York Heart Association angina classification predicted mortality, perioperative cardiac morbidity, and late complications. Estrogen therapy at the time of admission for coronary artery bypass grafting did not influence surgical mortality, perioperative cardiac morbidity, or early or late complications.     

Correlation between the European System for Cardiac Operative Risk Evaluation and sexual function after coronary artery bypass graft surgery

IntroductionThe published studies discussing the prognostic factors for expected sexual function after coronary artery bypass graft (CABG) are still limited.AimExamining the correlation between the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the abridged form of International Index of Erectile Function questionnaire (IIEF-5), as a quick and inexpensive tool for the cardiologist to predict the sexual function after CABG.Main Outcome MeasuresValidated standardized questionnaire commonly used by cardiologists in identifying appropriate weight to various risk factors related to adult cardiac operations.MethodsPreoperatively patients were evaluated as regards to the sexual function by (IIEF-5) and pharmaco-penile duplex ultrasound. Moreover all patients were evaluated bu EuroSCORE. Six months after surgery, the erectile function of all patients was revaluated according to the same preoperative procedures. The patients were categorized with EuroSCORE as follows: The low-risk group (EuroSCORE 0–2), the medium-risk group (EuroSCORE 3–5), and the high-risk group (EuroSCORE 6 plus).ResultsThe EuroSCORE was negatively correlated with the IIEF-5 score (r = ?0.224, P = 0.025 or rs = ?0.259, P = 0.009). Moreover, low-risk patients had significantly higher IIEF-5 scores compared with medium-risk patients (mean ± standard deviation = 15.27 ± 6.03 vs. 12.18 ± 6.07, P < 0.05).ConclusionsThere is an inverse correlation between the components of EuroSCORE and the IIEF-5 score. Patients with higher EuroSCORE had lower IIEF-5 scores and vice versa.The EuroSCORE is a useful, quick, and inexpensive tool that allows prediction of ED in those patients with coronary artery disease patients who are undergoing CABG. Mohamed OA, Hamed HA, Roaiah MF, Helmy T, Mahran A, and Bennett CJ. Correlation between the European System for Cardiac Operative Risk Evaluation and sexual function after coronary artery bypass graft surgery.     

Coronary artery bypass surgery utilizing right gastroepiploic artery.

Fifteen patients (10 men, 5 women), who underwent coronary artery bypass surgery utilizing the right gastroepiploic artery (R't GEAR) in combination with either the left internal mammary artery (LIMA) or the greater saphenous vein as graft material, were studied. The reasons for utilizing R't GEAR were previous coronary artery bypass operations with resulting marked wound adhesion prohibiting LIMA harvest (five cases), LIMA jeopardized during surgery (three cases), total arterial revascularization using LIMA + R't GEAR (four cases), and near total arterial revascularization using LIMA + R't GEAR + saphenous veins (SV) (three cases). A total of 40 coronary arteries were revascularized: the R't GEAR was used for revascularization of 11 left anterior descending arteries, three right coronary arteries, and one left circumflex artery; LIMA was used for revascularization of four left anterior descending arteries, and three diagonal arteries; the saphenous vein was used for revascularization of eight left circumflex arteries, three diagonal arteries, six posterior descending arteries, and one proximal right coronary artery. There were no hospital mortalities, and follow-up studies revealed satisfactory early results. From our preliminary experience with these 15 cases, we assume that the R't GEAR can be used as the graft material of choice for coronary artery bypass in cases where difficulty in LIMA utilization is encountered or insufficient vein graft conduit is available. It is particularly valuable in reoperations for coronary arterial disease.     

Pregnancy in a patient with a history of myocardial infarction and coronary artery bypass grafting

A 37-year-old woman conceived after experiencing a myocardial infarction and undergoing three-vessel aortocoronary artery bypass grafting. Pregnancy was complicated by angina, which was successfully treated with propranolol and bed rest. At term the patient underwent vaginal delivery, without evidence of intrapartum myocardial ischemia or failure.     

Risk factors for ICU mortality in critically ill patients.

BACKGROUND AND PURPOSE: Advances in critical care medicine have increased the chances of survival for patients with severe illness or trauma. However, such patients consume a large proportion of medical resources. This study sought risk factors for mortality that have potential to be modified among patients treated in medical or surgical intensive care units (ICUs). METHODS: This 6-month prospective observational study was conducted in the medical and surgical ICUs of an 1,800-bed university hospital. All adult patients with an expected ICU stay of 48 hours or more were followed up regularly until discharge from the ICUs, or for 10 weeks during their stay in ICUs. RESULTS: Of 342 patients enrolled, 77 (22.5%) died during a median follow-up period of 5 days (range, 2-70 days). Among a range of variables at the time of ICU entry or developing during stay in ICUs, 17 were associated with higher mortality rate. Multivariate analysis using a logistic regression model demonstrated that the presence of systemic inflammatory response syndrome (SIRS) at the time of ICU entry (adjusted relative risk, ARR, 2.85; 95% confidence interval, CI, 1.16-7.05), Acute Physiological and Chronic Health Evaluation (APACHE) II score on ICU Day 4 (ARR 1.12 with increment of one score; 95% CI 1.01-1.24), Therapeutic Intervention Scoring System (TISS) score on Day 4 (ARR 1.13 with increment of one score; 95% CI 1.05-1.23), parenteral nutrition (ARR 4.97, 95% CI 1.73-14.26), and nosocomial Candida infection (ARR 3.39, 95% CI 1.12-10.23) were independently associated with ICU mortality. CONCLUSIONS: In addition to SIRS and the APACHE II and TISS scores, this study found that nosocomial Candida infection and parenteral nutrition were independently associated with mortality after control for admission conditions, severity of illness scores, and interventions.     

Successful rescue of sustained ventricular tachycardia/ventricular fibrillation after coronary artery bypass grafting by extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) can be set up quickly at the bedside and provides reliable temporary mechanical circulatory support for severe heart failure. We report the case of a 56-year-old female with circulatory collapse due to sustained ventricular tachycardia and ventricular fibrillation (VT/Vf) after coronary artery bypass grafting (CABG) who was successfully resuscitated using ECMO. The sustained VT/Vf might have been secondary to myocardial stunning, ischemia, infarction, or reperfusion. There were 40 cardioversions within the first 5 postoperative days. The patient improved after 8 days of ECMO in addition to use of an intraaortic balloon pump and administration of inotropic agents for profound heart failure. Left ventricular ejection fraction improved from 28% preoperatively to 54.5% on the 20th postoperative day. Cardiogenic shock due to sustained VT/Vf after CABG may be an indication for ECMO support. Immediate establishment of circulatory support using ECMO provides valuable time for spontaneous and interventional correction of reversible causes of sustained VT/Vf.     

Risk factors for pelvic surgery

One hundred and eighty four women who had corrective surgery for stress incontinence, genital prolapse or both were compared with two hundred and ninety women who had no surgery for these conditions. Patients and controls did not differ in terms of age, height, weight or body mass index. Younger age at first delivery (20.1±4.1 vs 22.8±4.9, p<0.000) and a smoking history (33.2% vs 23%, p<0.015) were found as risk factors for the study group. Women who underwent surgery had greater gravidity (4.85±2.9 vs 3.87±2.5, p<0.001), greater parity (3.03±1.9 vs 2.19±1.3, p<0.000), were less often nulliparous (2.2% vs 7.9%, p<0.008), less likely to have had a cesarean delivery (1.1% vs 9%, p<0.001) and more likely to have had a vaginal delivery (97.3% vs 85.9%, p<0.000) than the control group. The study group have had larger neonates on average (3800±416 vs 3373±637 gm’s, p<0.000) and had greater use of forceps or vacuum extractor for at least one delivery (17.9% vs 7.6%, p<0.001). Highly significant relationship was found between the risk of having corrective surgery and the number of children born vaginally. Women who had 4 or more vaginal deliveries had 11.7 times more risk of urinary incontinence or genital prolapse. Received: 11 June 2001 / Accepted: 25 September 2001 Correspondence to Y. E. Erata     

Risk factors for primary postpartum haemorrhage

The objective of the study was to determine which background factors predispose women to primary postpartum haemorrhage (PPH) at the Obafemi Awolowo University Hospital. The study consisted of 101 women who developed PPH after a normal vaginal delivery and 107 women with normal unassisted vaginal delivery without PPH Both cases and controls were investigated for sociodemographic risk factors, medical and obstetric histories, antenatal events and labour and delivery outcomes. Data were abstracted from the medical and delivery records and risks were estimated by multivariate logistic regression. The results of the unvariate analysis revealed a number of potential risk factors for PPH but after adjustment by logistic regression three factors remained significant. These were prolonged second and third stages of labour and non-use of oxytocics after vaginal delivery. Previously hypothesised risk factors for PPH such as grand multiparity, primigravidity and previous episodes of PPH were not significantly associated with PPH. We conclude that primary PPH in this population is mostly associated with prolonged second and third stages of labour and non use of oxytocics. Efforts to reduce the incidence of PPH should not only be directed at proper management of labour but also training and retraining of primary health care workers and alternative health care providers in the early referral of patients with prolonged labour.     

Risk factors for neonatal mortality among extremely-low-birth-weight infants

OBJECTIVE: The purpose of this study was to examine characteristics associated with neonatal mortality among extremely low-birth-weight infants (< or = 1000 g). STUDY DESIGN: A population-based, case-control study using linked Missouri birth and death certificates from 1989 to 1997 was conducted. Cases (n = 835) were defined as extremely low-birth-weight infants that died within 28 days of birth. Controls (n = 907) were randomly selected from extremely low-birth-weight infants that were alive at 1 year and were frequency matched to subjects by birth year and birth weight. RESULTS: Infants born with severe congenital anomalies and at the youngest gestational ages were at greatest risk for neonatal mortality. Other significant risk factors included maternal age (< 18 and > 34 years), vaginal delivery, nontertiary hospital care, malpresentation, male gender, and small for gestational age. Black race and preeclampsia were protective against early death. CONCLUSIONS: The risk of neonatal mortality among extremely low-birth-weight infants was associated with several maternal, infant, and obstetric factors, some of which may be preventable.     

Risk factors associated with coronary artery calcification in midlife women: a population-based study

Abstract

The aim of this study was to investigate the association between individual risk factors and coronary artery calcification (CAC), as a marker of subclinical cardiovascular disease, in a population-based nested cross-sectional study of midlife women. Anthropometric and metabolic data from 295 women from the South of Brazil were analyzed. Habitual physical activity was assessed by pedometer. CAC was assessed by a multi-detector computed tomography system. Average Agatston score was used to stratify participants as CAC?>?0 and CAC?=?0. Women with CAC?>?0 (34.7%) were older (58.7?±?5.4 vs. 56.3?±?5.2?years, p?<?.001) and had higher prevalence of central adiposity (71 vs. 59%, p?=?.04) and hypertension (71 vs. 52%, p?=?.002) than women in the CAC?=?0 group. Hormone therapy (HT) was more prevalent in the group with CAC?=?0 (19.7 vs. 9.8%, p?=?.029). The prevalence ratios for CAC?>?0 were 0.545 (95%CI:0.309–0.962, p?=?.036) for HT and 1.752 (95%CI:1.207–2.541, p?=?.003) for hypertension, after adjustment for age, educational level, smoking, alcohol intake, and physical activity. The present data in a population-based sample of midlife women indicate that hypertension and age were positively associated with higher risk for CAC?>?0 and HT was related with CAC?=?0.     

Feasibility and short-term results of total arterial coronary artery bypass in Taiwanese.

BACKGROUND AND PURPOSE: Long-term results of coronary artery bypass are limited by progressive atherosclerosis in venous conduits. Arterial conduits are believed to have a better patency rate. A radial artery in composite graft with the left internal thoracic artery makes total arterial revascularization possible in almost all patients. We sought to evaluate the feasibility and short-term results of this grafting strategy. METHODS: A total of 381 consecutive patients received elective coronary artery bypass grafting between 1 May 2000 and 31 August 2002. Patients with associated procedures were also included. There were 333 patients without venous conduits. Patients with left ventricular dysfunction were not excluded from total arterial revascularization. Follow-up time was 13.7 +/- 7.6 months. RESULTS: Total arterial revascularization was achieved in 88% of the patients. Arterial harvest was easy and simple and complete revascularization could be achieved. The 30-day overall mortality rate was 3.29%. In the patients with left ventricle ejection fraction greater than 0.4, the mortality rate was 2.32%. There were 6 late deaths: heart failure in 2, sepsis in 2, respiratory failure in 1, and pneumonia in 1. CONCLUSIONS: It is feasible to use total arterial grafts for coronary artery bypass graft in patients with coronary artery disease. Myocardial revascularization can be complete and the early mortality rate is acceptable.     

Risk factors affecting in-hospital mortality in patients with nosocomial infections.

BACKGROUND/PURPOSE: Nosocomial infection (NI)-associated death is an important issue for both patients and clinicians, and is of emerging importance in public health. This study investigated the factors associated with in-hospital deaths among patients with NI. METHODS: Between July 1, 2002 and June 30, 2003, a total of 1574 patients with NI at National Taiwan University Hospital were enrolled to investigate the factors associated with fatal outcome. Host factors, hospital services, surgical and medical interventions, microbial factors, infection sites, and the treatment and complications of NI were analyzed retrospectively. RESULTS: During the study period, 554 of the 1574 patients died (mortality rate, 28.3%). NI was directly involved in 80.5% of them (n = 446), and over two-thirds (67.9%) of deaths occurred within 2 weeks of NI onset. Sixteen variables were statistically implicated as independent factors significantly associated with mortality. Host factors included higher disease severity (p < 0.0001), liver cirrhosis (p < 0.0001), solid tumors (p < 0.0001), chronic lung disease (p = 0.003), and congestive heart failure (p = 0.005). Hospital and interventional factors included intensive care hospitalization (p = 0.002), longer hospitalization before NI onset (p = 0.004), hemodialysis (p = 0.0003), arterial-line insertion (p < 0.0001), urinary catheterization (p < 0.0001), and central venous catheterization (p = 0.001). Blood stream infections (p < 0.0001), NI due to Candida (p < 0.0001), and multiple (> or = 2) episodes of NI (p < 0.0001) were significant risk factors for death, as were occurrence of NI-associated septic shock (p < 0.0001) and disseminated intravascular coagulation (p < 0.0001). No significant associations of mortality with age, sex, species of bacteria, multi-antibiotic resistant bacteria, regimen for initial treatment, or multiple antibiotic therapy were evident. CONCLUSION: Measures that prevent the occurrence of NI, such as improving the immunity status of the host, removal of catheters as soon as possible, and implementing an infection control program, could reduce the risk of in-hospital deaths attributable to NI.