Perioperative risk of aortic valve replacement after coronary artery bypass grafting

OBJECTIVE: To evaluate the operative risk of aortic valve replacement (AVR) after coronary artery bypass grafting (CABG). METHODS: Twenty patients (sixteen male, four female) underwent AVR 1.5-20 years (mean: 8.2) after CABG. RESULTS: Patients had received a mean number of four bypass grafts (2-5) with the use of the left internal thoracic artery in seventeen patients. Mean age at the time of AVR was 70.5 years (57-82). All patients suffered from an aortic stenosis with a mean orifice area of 0.74 cm (2) (0.34-1.1) and a mean pressure gradient of 52.4 mm Hg (22-78). Ten mechanical (mean diameter 23.6 mm, 21-27) and ten biological (22.1 mm, 19-25) prostheses were implanted. Mean duration of surgery, cardiopulmonary bypass (CPB) and cross-clamp time were 322.1 (205-645), 169.2 (87-411), and 77.1 (46-128) minutes, respectively. Fourteen patients had an uneventful postoperative course. A temporary neurological impairment, renal failure, and re-intubation for respiratory insufficiency for nine hours occurred in one patient each. Two patients died postoperatively (day 3 and 10) due to multiple cerebral infarctions. One patient required a replacement of the ascending aorta in deep hypothermia and re-implantation of the bypasses. He suffered from gastrointestinal bleeding on postoperative day 14 and expired on day 81 because of multi-organ failure. CONCLUSION: Aortic valve replacement after coronary artery bypass grafting is associated with an enhanced perioperative risk requiring meticulous decision-making and a sophisticated operative technique.     

Combined coronary artery bypass grafting and abdominal aortic aneurysm repair

The purpose of this paper was to assess the results and feasibility of simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair. Twenty nine patients with a mean age of 65 years underwent simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair between June 1990 and March 2002. All patients had significant coronary artery disease and were considered as indicated for coronary artery bypass grafting. This was performed first in 28 patients and simultaneously with abdominal aortic aneurysm repair in one, with a mean number of grafts of 2.5, a mean aortic cross-clamp time of 40 minutes, and a mean bypass time of 115 minutes. Eight straight and 21 bifurcated grafts were employed. The total operating time averaged 400 minutes. The median postoperative hospital stay was 18 days. One patient died of stroke and mediastinitis, for a mortality rate of 3.5%. This experience suggests that combined coronary artery bypass grafting and abdominal aortic aneurysm repair is both safe and effective.     

Risk factors for severe coronary artery disease - a case-control study of patients who have undergone coronary artery bypass grafting

To investigate risk factors for coronary artery disease (CAD), we analyzed the clinical parameters of patients with a coronary artery bypass graft (CABG) in a case-control study. Eighty-eight patients (75 males and 13 females) who underwent CABG surgery between 2001 and 2002 were compared with age- and sex-matched healthy controls randomly chosen from the registry of Kobari Health Care Center. Wilcoxon's signed rank test and McNemar's test were used for pairwise comparisons. Multivariate logistic regression analysis was used to identify significant risk factors for CABG. Significant differences between the patients and controls were observed in HDL-C (p < 0.001), HbA(1c) (p < 0.001), Brinkman Index (BI; p < 0.001), body mass index (BMI; p = 0.002), and systolic blood pressure (SBP; p = 0.013). Subjects with an abnormal BMI, HbA(1c), or HDL-C or high BI value made up a significantly higher proportion of the patients who underwent CABG, compared to their age- and sex-matched controls. Multivariate logistic regression analysis identified high levels of HbA(1c), low levels of HDL-C, and high scores on the BI as significant risk factors for needing a CABG. These results demonstrate that, despite the modification of laboratory determinations by antecedent treatment, HDL-C, HbA(1c), BI, BMI, and SBP are significant indicators of risk for CAD.     

Hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with internal mammary arteries in children with Kawasaki disease

BACKGROUND. Saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts have been used for coronary artery bypass grafting. In adult patients with bypass grafting for atherosclerotic coronary artery disease, IMA grafts have been reported to have long-term patency; however, results are conflicting on whether the graft is sufficient to meet increased myocardial oxygen demand during exercise. There have been no studies on hemodynamics and blood flow during exercise after bypass grafting with IMA in pediatric patients with Kawasaki disease. METHODS AND RESULTS. We studied 17 pediatric patients with Kawasaki disease (average age, 7.5 +/- 3.1 years), who underwent coronary artery bypass grafting with the IMA. The average number of coronary artery bypass grafts was 2.1 +/- 0.7/patient. For all patients, the left IMA was anastomosed to the left anterior descending coronary artery; for eight patients, the right IMA was also anastomosed to the right coronary artery. In addition, 11 SVGs were used. The postoperative patency rates after 1 month were 100% with the IMA graft and 91% with SVG. One year after the operation, the patency rates were 100% with IMA and 50% with SVG. Hemodynamics during exercise were measured with a bicycle ergometer, and coronary sinus blood flow was measured by the continuous thermodilution method in six patients. The relation between delta LVEDP (the difference between left ventricular end-diastolic pressure at rest and during exercise) and delta SVI (the difference between the stroke volume index at rest and during exercise) was analyzed. Four of six patients had reduced cardiac function before operation (delta LVEDP, positive; delta SVI, negative). However, after the operation, all patients demonstrated improvements in cardiac function during exercise (delta LVEDP, positive; delta SVI, positive). Coronary sinus flow per left ventricular mass increased after operation from 70 +/- 46 to 87 +/- 56 ml/min at rest (p less than 0.05) and from 139 +/- 118 to 183 +/- 150 ml/min during exercise (p less than 0.05). CONCLUSIONS. In conclusion, this study reveals improvements in both hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with IMA grafts in pediatric patients with Kawasaki disease.     

Risk score for predicting abdominal complications after coronary artery bypass grafting

BACKGROUND Although early abdominal complications after coronary artery bypass grafting(CABG) with cardiopulmonary bypass(CPB) are rare, the associated mortality remains high.AIM To develop a risk score for the prediction of early abdominal complications after CABG with CPB.METHODS This retrospective study was performed in the Federal State Budgetary Establishment Federal Center of Cardiovascular Surgery of the Ministry of Health of Russia(the city of Chelyabinsk) and included data of 6586 patients who underwent CABG with CPB during 2011-2017. The risk factors taken for evaluation were compared between patients with early abdominal complications(n = 73) and without them(n = 6513). We identified the most important risk factors and their influence on the development of early abdominal complications after CABG with CPB.RESULTS Gender and the presence of postinfarction cardiosclerosis, chronic kidney disease, or diabetes in the anamnesis did not affect the occurrence of abdominal complications. The leading risk factors of the early abdominal complications after CABG with CPB were multifocal atherosclerosis, extracorporeal membrane oxygenation, intra-aortic balloon pump, atrial fibrillation, perioperative myocardial infarction, and the need for resternotomy in the postoperative period. The average value of the predicted probability was 0.087 ± 0.015 in patients with early abdominal complications after CABG with CPB and 0.0094 ± 0.0003 in patients without these complications. The percentage of correct classification turned out to be 98.9%. After calculating a score for each of the leading risk factors, we counted a total score for each particular patient. The highest risk was noted in patients with a total score of 7 or more.CONCLUSION The developed score predicts the risk of early abdominal complications after CABG with CPB and makes it possible to stratify patients by risk groups.     

Coronary artery bypass grafting in a child with Kawasaki disease

Kawasaki disease (KD) with cardiac involvement can result in the development of coronary aneurysm, stenosis or thrombosis with significant cardiovascular implications. We report the case of a 23-month-old male with a late diagnosis of KD, in whom intravenous immunoglobulin treatment was not feasible. The patient's course was assessed by routine echocardiography. At the age of five years, angiographic assessment revealed an aneurysm of the anterior descending coronary artery measuring 17 mm×7 mm involving the first diagonal branch, 90% post-aneurysmal stenosis, and an aneurysm of the right coronary artery measuring 32 mm×6 mm. Due to the critical anatomy of the anterior descending artery the revascularization method of choice was coronary artery bypass surgery with an internal mammary artery graft, under cardiopulmonary bypass. There were no significant intraoperative or postoperative complications. This confirms coronary artery bypass grafting as a reliable treatment option for patients who present with coronary sequelae from KD, even at a very young age.     

Five year clinical follow up of patients who have had off pump coronary artery bypass grafting

Background: Off pump coronary artery bypass (OPCAB) has become a common technique for conducting coronary artery surgery. There has been some concern that the anastomoses might not be conducted as effectively on the beating heart, which could lead to poor long-term results. The aim of the present study was to follow up all patients who had undergone OPCAB at our institution to determine clinical outcomes up to 5 years postoperatively.

Methods: All living patients who had undergone OPCAB up until December 2000 were telephoned. For those who could be contacted, a detailed questionnaire was completed and the data were analysed.

Results: The technique of OPCAB was carried out on 312 patients. Thirteen of these patients died, five perioperatively. Actuarial survival at 5 years was 94.6% and freedom from cardiac related events was 92.1%. There were only two patients with angina worse than class I. Patients showed a high rate of compliance with risk factor management. Forty per cent of patients claimed to have had psychological problems related to the surgery.

Conclusions: Mid-term results of OPCAB are very satisfactory, but randomised trials are needed to see whether they are different from the results of conventional coronary artery bypass grafting.     

Redo off-pump coronary bypass grafting with arterial grafts for Kawasaki disease

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease is relatively uncommon. The late stenosis of the saphenous vein graft is the problem to be solved. We report a case of redo off-pump coronary bypass grafting in a 35-year-old man, 20 years after bypass grafting using a saphenous vein graft. Off-pump total arterial revascularization was performed uneventfully. The procedure comprised grafting of bilateral internal thoracic arteries to left anterior descending branch and obtuse marginal branch, and radial artery to AV branch and posterior descending branch. Off-pump total arterial revascularization is a safe and less invasive procedure at the time of redo operation, even for patients with Kawasaki disease.     

Results of concomitant aortic valve replacement and coronary artery bypass grafting in the VA population

BACKGROUND AND AIM OF THE STUDY: Concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) is an established risk factor for diminished postoperative survival. Results from a VA population were reviewed in order to determine factors influencing early and late survival. METHODS: Between 1993 and 2003, a total of 401 patients underwent AVR at the authors' institution. Of these patients, 249 (62%; mean age 70.6 years) had combined AVR and CABG. Surgical indications were primarily aortic valve pathology (group A: n = 168; 68%), primarily coronary artery disease (CAD) (group B: n = 55; 22%), and both severe aortic and coronary disease (group C: n = 26; 10%). In total, 177 patients (71%) received a bioprosthesis, and 72 (29%) received a mechanical valve. Short- and long-term outcomes were explored using univariate and multivariable hazard analyses. RESULTS: Overall operative mortality was 6.4%; mortality for groups A, B and C was 4.8%, 9.1% and 11.5%, respectively. On multivariable analysis, significant factors associated with early-phase mortality were NYHA class IV, diabetes, bioprosthetic valve and combined severe aortic and coronary disease. Survival at one and five years was 86% and 62%, respectively. Five-year survival for groups A, B and C was 71%, 63% and 54%, respectively. Significant associated factors for late-phase mortality were the presence of preoperative peripheral vascular disease (PVD) and cerebrovascular disease (CVD). Factors such as age, prior cardiac surgery, number of grafted coronary arteries, and/or effective orifice area index (EOAI) had no significant effect on outcome. CONCLUSION: Combined AVR/CABG is a marker for decreased survival. Pre-existing factors such as diabetes, PVD and CVD, as well as poor preoperative NYHA functional status, affected survival. Further investigation is needed to assess the influence of the severity of CAD and EOAI on survival. Thoughtful consideration of all these factors is essential for an accurate prediction of survival, and to determine the appropriate type of aortic prosthesis to be used.     

Multiarterial coronary artery bypass grafting with special reference to small vessel disease and results in women

From 1985 to 1991 a total of 220 patients underwent coronaryartery bypass grafting (CABG) with at least two native pedicledartery grafts. Bilateral internal mammary artery (IMA) graftingwas performedin 201 patients, IMA combined with gastro-epiploicartery (GEA) grafting in five, and double IMA plus GEA graftingin 14; in addition 156 patients received 1–3 vein grafts.The primary indication for elective multi-arterial CABG wascoronary arteries of small calibre (small vessel disease) in77 patients, repeat CABG in 17 (without small vessel disease),varicose/stripped saphenous veins in 57 (without small vesseldisease), while the remaining 69 were routine cases; the distributiondiffered between women (42, 0, 47, and 11%, respectively) andmen (33, 10, 19, and 38%, respectively; P<0.0001). The womenalso were older (62±7 vs 56±9 years; P<0.0001),and had higher prevalences of systemic hypertension, diabetesmellitus, and hypercholesterolaemia. The number of artery graftsand total number of grafts were, however, similar for womenand men. Early mortality (30 days) was 5.6% in women and 2.4%in men (ns). Early mortalities in relation to primary indicationswere: 7.8% for small vessel disease, 5.9% for repeat CABG, and0% for both varicose/stripped saphenous veins androutine cases(P<0.05). Logistic regression analysis identified small vesseldisease, insufficient grafting, age of 60 years, a historyof smoking, a family history of ischaemic heart disease, andfemale gender as independent risk factors for early mortality.Stratified analysis of early mortality for gender against eachof the other risk factors showed that the influence of femalegender was explained by a significantly more pronounced impactof small vessel disease in women than in men. Intraoperativeflow measurements in the IMA grafts showed no difference betweenmen and women, and postoperative angiographic artery graft patencywas 92% in men and 94% in women. An aggressive approach withmultiple artery grafting thus seems justified in any situationwith exhausted venous reserves. Small vessel disease representsa special indication for primary multiple arterial grafting;the higher prevalence and more severe impact of small vesseldisease makes optimal graft quality and surgical anastomosistechnique especially important in women.     

Combined coronary artery bypass grafting on the beating heart and abdominal aortic aneurysm repair.

Abdominal aortic aneurysm (AAA) is commonly associated with coronary artery disease (CAD). Eleven patients underwent the combined operation of coronary artery bypass grafting (CABG) on the beating heart and AAA repair: 10 underwent off pump CABG and 1 patient required centrifugal pump and pulmonary assist with closed circuit because of unstable hemodynamics. All cases were discharged without severe complications and with patent coronary bypass grafts.     

Long-term survival and prognostic implications after coronary artery bypass grafting in Chinese patients with coronary artery disease

OBJECTIVES: This hospital-based study was conducted to determine the survival rates of patients after coronary artery bypass grafting (CABG) surgery and the associated prognostic factors related to all-cause mortality during a 7-year follow-up in Taiwan. METHODS AND RESULTS: Between January 1997 and December 2003, the medical records of 1877 patients who underwent primary, isolated CABG surgery were studied. The Kaplan-Meier method was used to estimate survival. Multiple Cox regression was used to investigate the independence of prognostic factors associated with all-cause mortality. Of the 1877 patients who underwent CABG surgery, 192 expired during the 7-year study period.The overall patient survival rate was 85.96% (95% CI: 83.74-88.16). Using multiple Cox regression analysis, in addition to female gender, older age at surgery, pulmonary oedema, longer ischaemic time, longer cardiopulmonary bypass time, and poorer postoperative left ventricular ejection fraction were significant factors associated with all-cause mortality for both men and women. Associated prognostic factors varied by gender. For men, smoking (RR = 2.82, 95% CI: 1.06-4.16), respiratory failure (RR = 6.88, 95% CI: 3.29-14.40) and cardiogenic shock (RR = 4.04, 95% CI: 2.13-7.67) were significantly related to all-cause mortality, but not for women. Sepsis (RR = 8.97,95% CI: 1.19-19.81) and ICU stay (RR = 1.03,95% CI: 1.01-1.05) were significantly related to all-cause mortality among female patients only. CONCLUSIONS: Several gender-related differences were noted pertaining to all-cause mortality and the relationships between smoking, sepsis, respiratory failure, cardiogenic shock, and ICU stay.     

Percutaneous transluminal coronary angioplasty for anastomotic stenosis after coronary arterial bypass grafting in Kawasaki disease

OBJECTIVES: We evaluated the efficacy of percutaneous transluminal coronary angioplasty for anastomotic stenosis after coronary arterial bypass grafting using the internal thoracic artery in patients with coronary arterial lesions due to Kawasaki disease. SUBJECTS AND METHODS: From July 1997 to April 2000, four boys and one girl underwent percutaneous transluminal coronary angioplasty for 6 anastomotic lesions following coronary arterial bypass grafting using the left or right internal thoracic artery. Progressive severe stenosis of the grafts in the follow-up angiograms after grafting, and evidence of ischemia, were regarded as indications for percutaneous transluminal coronary angioplasty. Age at coronary angioplasty ranged from 4.2 to 16.7 years, with a median of 6.9 years, while the interval from operation ranged from 0.3 to 3.0 years, with a median of 1.1 years. The diameter of the balloon catheter employed varied from 1.5 to 2.5 mm, and the pressure of inflation ranged from 8 to 16 atmospheres. RESULTS: The degree of stenosis decreased from 63 to 99%, with a median of 88%, to 0 to 40%, with a median of 17% immediately after angioplasty. A follow-up angiogram either 3 months or 1 year later revealed no restenosis in any patient. CONCLUSION: Percutaneous transluminal coronary angioplasty is a feasible and useful procedure for treating anastomotic stenosis following coronary arterial bypass grafting using the internal thoracic artery in patients with coronary arterial lesions due to Kawasaki disease.     

Aortic valve replacement and combined aortic valve replacement and coronary artery bypass grafting: predicting high risk groups

To determine which groups of patients are at highest risk for operative or late mortality, 259 consecutive patients who underwent operation between 1978 and 1984 were studied; 170 underwent aortic valve replacement and 89 underwent aortic valve replacement combined with coronary artery bypass grafting. Multivariate analysis of risk factors selected emergency operation and patient age older than 70 years as the strongest predictors for operative death. Although patients having aortic valve replacement and coronary artery bypass grafting had a higher operative mortality rate (13.5 versus 3.5%), the combined operation had no independent predictive effect on early or late results. At a mean follow-up time of 48 months after surgery, 72% of the survivors of operation were living, 10% were lost to follow-up and 18% were dead. Seventy-seven percent of long-term survivors were in New York Heart Association functional class I or II. The incidence of thromboembolism, paravalvular leak, bacterial endocarditis and hemorrhage each occurred at a rate of less than 1% per patient-year. The factors associated with late death were preoperative age, male sex, left ventricular end-diastolic pressure, cardiac index and functional class. Despite an increase in operative mortality, patients undergoing emergency operation were not at higher risk of late death. Operative mortality is concentrated among several high risk groups. For patients undergoing elective operation, operative mortality is low, especially if the patient is less than 70 years old. Late results are good for all groups of patients undergoing operation, including those who are at greater risk of dying at operation.     

Combined coronary artery bypass graft and abdominal aortic aneurysmectomy

Six cases of combined coronary artery bypass graft and abdominal aortic aneurysmectomy were performed in a 1-year period at the Washington Hospital Center. All cases except one were uncomplicated and the average hospital stay for patients with no complications was less than 10 days. We found that there were distinct advantages in combining these two procedures. Although our experience is limited and no definite criteria for combining such procedures have been established, we feel that this approach has potential as the treatment of choice in patients with severe coronary artery disease and abdominal aortic aneurysm.