Limitations in the cardiac risk reduction provided by coronary revascularization prior to elective vascular surgery

OBJECTIVE: The objective of this study was to evaluate the proposed cardiac protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) before elective major arterial surgery. METHOD: Preoperative cardiac risk stratification using American College of Cardiology/American Heart Association (ACC/AHA) guidelines was done on 425 consecutive patients undergoing 481 elective major vascular operations at an academic VA Medical Center. The algorithm assumed asymptomatic patients with prior coronary revascularization (CABG, <5 year; PTCA, <2 year) were low cardiac risk. Coronary angiography was done for recurrent symptoms with secondary intervention when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of vascular surgery were compared between patients with and without previous CABG or PTCA by contingency table and logistic regression analyses. RESULTS: Coronary revascularization was classified as recent (CABG, <1 year; PTCA, <6 months) in 35 cases (7%), prior (1 year < or = CABG < 5 year, 6 months < or = PTCA < 2 year) in 45 cases (9%), and remote (CABG, > or = 5 year; PTCA, > or = 2 year) in 48 cases (10%). A larger fraction of patients with previous revascularization possessed pathologic cardiac risk variables and were stratified as high-risk preoperatively than their nonrevascularized counterparts. Outcomes in patients with previous PTCA were similar to those after CABG (P =.7). Significant differences in adverse cardiac events (P =.01) and mortality (P =.05) were found between patients with CABG done within 5 years or PTCA within 2 years (6.3%, 1.3%, respectively), individuals with remote revascularization (10.4%, 6.3%), and nonrevascularized patients stratified at high risk (13.3%, 3.3%) or intermediate/low (2.8%, 0.9%) risk. De novo or recurrent 3-vessel coronary disease by angiography, but not the presence or timing of previous revascularization, was an independent predictor of cardiac events after vascular operations, whereas remote revascularization was associated with fatal outcomes by multivariate analysis. CONCLUSIONS: Previous coronary revascularization (CABG, <5 years; PTCA, <2 years) may provide only modest protection against adverse cardiac events and mortality following major arterial reconstruction.     

冠状动脉旁路移植术后长期随访

目的 总结１９８２年至１９９１年间３８例冠状动脉旁路移植术（ＣＡＢＧ）者的长期随访结果,以探讨术前危险因子对ＣＡＢＧ疗效的影响。方法 ３８例中男３６例,女２例。年龄４１－７３岁,平均５５．４岁,７３．７％病人年龄大于５０岁。有心肌梗死发作史者１５例,有心衰史者２例。ＰＴＣＡ失败后急症手术２例,３支,３支以上冠状动脉病变者１９例。心功能Ⅲ级及以上者３０例。应用Ｓｔａｔｉｓｔｉｃａ软件包中的Ｌｏｇｉｓ     

Coronary artery disease in patients with abdominal aortic aneurysm

Selective coronary angiography to determine the prevalence of coronary artery disease (CAD) has been performed in patients with abdominal aortic aneurysm (AAA). Thirty patients in this series consisted of 26 men and 4 women with an age range of 48-87 years (mean +/- SD: 67.5 +/- 8.2 years). As the atherosclerotic risk factors, cigarette smoking was present in 19 patients (63.3%), hypertension was in 18 (60%), hypercholesteremia was in 10 (33.3%), and diabetes mellitus was in 2 (6.7%). Cerebral vascular disease was present in 11 patients (36.7%). Regarding CAD, angina pectoris or old myocardial infarction was found in 9 patients (30%), and abnormal electrocardiography (ECG) was in 16 patients (53.3%). Coronary angiography prior to operation of AAA was performed to 22 patients (73.3%), and 15 patients (68.2%) among them had significant coronary artery stenosis, and 9 patients underwent myocardial revascularization (4 CABG, 5 PTCA). CAD was frequently complicated both in patients without symptoms or ECG abnormalities and in less than 65-year patients. In order to prevent fatal myocardial infarction, we recommend routine coronary angiography to patients with AAA. And if necessary, myocardial revascularization must be indicated prior to aneurysmectomy.     

Effect of age in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial

BACKGROUND: The influence of age on the relative success of either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients requiring myocardial revascularization continues to be controversial. METHODS: In the Bypass Angioplasty Revascularization Investigation (BARI) trial, 1,829 patients with symptomatic multivessel coronary artery disease requiring revascularization were randomly assigned to undergo either CABG or PTCA. RESULTS: Seven hundred nine patients (39%) were 65 to 80 years old at baseline; the other 1,120 were younger than 65 years. The in-hospital 30-day mortality rate for PTCA and CABG in the younger patients was 0.7% and 1.1%, respectively, and that for patients 65 years or older was 1.7% and 1.7%, respectively. In older compared with younger patients, stroke was more common after CABG (1.7% versus 0.2%, p = 0.015) and heart failure or pulmonary edema was more common after PTCA (4.0 versus 1.3%, p = 0.011). In both age groups, CABG resulted in greater relief of angina and fewer repeat procedures. The 5-year survival rate in patients younger than 65 years was 91.5% for CABG and 89.5% for PTCA. In patients 65 years or older, the 5-year survival rate was 85.7% for CABG and 81.4% for PTCA. Cardiac mortality at 5 years was greater in patients assigned to the PTCA group than in those assigned to the CABG group. However, no significant treatment differences were noted in cardiac mortality when only nondiabetic patients were examined. CONCLUSIONS: Within the context of the Bypass Angioplasty Revascularization Investigation trial, older patients with multivessel coronary disease do well with either PTCA or CABG. Compared with younger patients, older patients had less recurrent angina and were less likely to undergo repeat procedures, particularly among those assigned to undergo CABG. Cardiac mortality was greater in patients 65 years or older assigned to undergo PTCA; however, this difference was not noted when treated diabetic patients were excluded from analysis.     

Coronary artery bypass surgery in patients with abdominal aortic aneurysm: detection and treatment of concomitant coronary artery disease.

OBJECTIVES: Complication due to coronary artery disease (CAD) is a major cause of mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The purpose was to show 1) the incidence of patients who required coronary artery bypass grafting (CABG), and 2) risk factors for the necessity of CABG in patients with AAA. METHODS: Subjects were consecutive 159 patients (132 males and 27 females) undergoing elective repair of non-ruptured AAA between May 1993 and March 2002. Most patients (n=145) underwent routine preoperative coronary angiography (CAG) and received coronary revascularization when necessary. Clinical atherosclerotic risk factors were subjected to univariate and multivariate analysis to determine predictors for the necessity of CABG. RESULTS: Of 43 patients (27.0%) with significant coronary stenosis, 7 patients (4.4%) underwent CABG concomitantly (n=1) or prior to the AAA repair (n=6) in the same admission. Other patients received percutaneous transluminal coronary angioplasty (PTCA) (n=14) and isolated medical treatment (n=22). Overall mortality of 159 patients undergoing AAA repair was 2.5% and there were no deaths in 7 patients undergoing CABG. Univariate and multivariate analysis indicated only the history of angina as significant for the necessity of CABG in patients with AAA. Of 155 survivors, 5 patients underwent CABG later in the follow-up period. CONCLUSIONS: The incidence of patients who required CABG in the treatment of AAA was 4.4% in our institute. It was difficult to predict the necessity of CABG without conducting CAG in patients with asymptomatic myocardial ischemia. These results may justify the routine enforcement of preoperative CAG in patients with AAA.     

Minimally invasive coronary artery bypass grafting decreases hospital stay and cost.

OBJECTIVE: The authors performed a retrospective cost analysis for patients undergoing revascularization of their left anterior descending (LAD) coronary artery either by standard coronary artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), or minimally invasive coronary artery bypass grafting (MICABG). SUMMARY BACKGROUND DATA: Minimally invasive CABG has become a safe and effective alternative treatment for single-vessel coronary artery disease. However, the acceptance of this procedure as a routine alternative for the treatment of coronary artery disease will depend on both long-term graft patency rates as well as a competitive market cost. METHODS: The authors conducted a retrospective analysis of three patient groups undergoing LAD coronary revascularization from January 1995 to July 1996. Ten patients were selected randomly from this period after PTCA of an LAD lesion with or without stenting. Nine patients underwent standard CABG on cardiopulmonary bypass with a left internal mammary artery. Nine patients received MICABG via a limited left anterior thoracotomy and left internal mammary artery to LAD grafting without the use of cardiopulmonary bypass. RESULTS: Percutaneous transluminal coronary angioplasty (n = 10) was unsuccessful in two patients. One patient in the MICABG group (n = 9) was converted successfully to conventional CABG because of an intramyocardial LAD and dilated left ventricle. There was no operative morbidity or mortality in any group. Average length of stay postprocedure was decreased significantly for both the MICABG and PTCA groups when compared with that of conventional CABG (n = 9) (2.7 + 0.26, p = 0.009, and 2.6 + 0.54, p = 0.006, vs. 4.8 + 0.46, respectively). Total hospital costs for the MICABG and PTCA groups were significantly less when compared with those of standard CABG ($10,129 + 1104, p = 0.0028, and $9113 + 3,039, p = 0.0001, vs. $17,816 + 1043, respectively). There were no statistically significant differences between the MICABG and PTCA groups. CONCLUSIONS: The final role of minimally invasive CABG is unclear. This procedure is clearly cost effective when compared with that of PTCA and conventional CABG. The long-term patency rates for MICABG will determine its overall efficacy.     

Outcome After Myocardial Revascularization and Renal Transplantation: A 25-Year Single-Institution Experience

BACKGROUND AND OBJECTIVE: Cardiac disease is a common cause of death in renal transplant recipients. This study retrospectively analyzes the results of myocardial revascularization procedures in these patients and makes recommendations for managing coronary atherosclerosis in patients with renal disease who already have a transplanted kidney or who may receive a kidney transplant. METHODS: Patients who had myocardial revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) and renal transplantation at the authors' institution between 1968 and 1994 were analyzed. Patient, procedural, and institutional variables were used for actuarial analyses of survival, as well as multivariate analyses of risk factors for death. RESULTS: Eighty-three of 2989 renal transplant patients required myocardial revascularization either before or after their transplant, and diabetes mellitus was the cause of renal failure in 42% of these patients. Standard coronary angiography, CABG, and PTCA techniques were used without periprocedural renal allograft loss. Actuarial patient survival was 89%, 77%, and 65% at 1, 3, and 5 years after the last procedure (transplantation or revascularization). Cardiac disease was the most common mode of death. Early-phase risk factors for death by multivariate analysis included hypertension and revascularization before 1989. Late-phase risk factors for death included diabetes mellitus, higher number of pre-CABG myocardial infarctions, renal transplantation before 1984, older age, and unstable angina before CABG. CONCLUSIONS: Myocardial revascularization can be performed with acceptable short- and long-term results in patients with renal disease who have renal transplantation either before or after the revascularization procedure. Diabetes mellitus was a highly prevalent condition among these patients, and cardiac disease was their most common mode of death. PTCA and CABG, as performed at this institution, posed little risk for renal allograft loss. Modification of risk factors for coronary atherosclerosis, rigorous cardiac evaluation of patients at risk for coronary artery disease before renal transplantation, and aggressive use of revascularization procedures to decrease the incidence of myocardial infarction are proposed as ways to prolong the survival of renal transplant patients with ischemic heart disease.     

Influence of Coronary Artery Disease on Operative Mortality and Long-Term Survival After Abdominal Aortic Aneurysm Repair

Purpose This retrospective study was conducted to evaluate the effects of coronary artery disease (CAD) on short- and long-term survival after abdominal aortic aneurysm (AAA) repair.Methods One hundred consecutive patients underwent elective AAA repair between 1991 and 2002. Coronary angiography was performed in all patients, revealing significant coronary artery lesions in 47 (47%). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 11 patients, 20 (median) days before the abdominal surgery. Abdominal aortic aneurysm repair was performed 60 (median) days after coronary artery bypass grafting (CABG) in five patients, and both procedures were performed simultaneously in two patients.Results The in-hospital mortality rate for AAA repair was 1.0%, but there was no cardiac-related operative morbidity or mortality. The 96 patients discharged were followed up for a mean period of 2.9 years (range 3–143 months). The cumulative survival rates after 1, 2, 3, and 5 years were 98%, 95%, 88%, and 77%, respectively. Only one patient (1%) died of myocardial infarction. There was no significant difference in the long-term survival of the CAD and non-CAD patients.Conclusions These results emphasize the importance of routine coronary angiography and subsequent coronary revascularization to improve early and late survival rates after AAA repair.     

Myocardial revascularization in patients with end-stage renal disease: Comparison of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Background: Ischemic heart disease is the major cause of death inpatients with end-stage renal disease. The high prevalence of coronary artery disease results in a rising number of dialysis patients requiring myocardial revascularisation. Objective: The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions and cardiovascular death following percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) inpatients with end-stage renal disease. Patients and methods: In a retrospective investigation 40 patients with chronic renal failure undergoing primarily PTCA and 65 patients undergoing CABG were included. Both groups were comparable for gender, duration on dialysis and the number of cardiovascular risk factors per patient. Patients undergoing PTCA were younger (53 ± 12 years vs. 57 ± 8 years; p < 0.05) and more often diabetics (30% vs. 14%; p < 0.05). Results: Most patients in both groups had a multi-vessel disease (95% in the CABG group vs. 74% in the PTCA group), in the CABG group there were significantly more patients with a triple-vessel disease (62% with vs. 40%in the PTCA group; p < 0.01), PTCA was primarily successful in 95% of the patients while complete revascularization was achieved in 88% of patients undergoing CABG. The perioperative mortality after CABG was 4.8% as compared to none after interventional revascularisation. The cumulative freedom of angina after 6, 12 and 24 months after intervention was significantly lower after PTCA (54%, 40%, 29%) than after bypass grafting (97%, 94%, 90%, p < 0.001). The frequency of reinterventions following PTCA was significantly higher compared to patients following CABG (p < 0.001). After PTCA 15 patients needed further revascularisations, 8 of them underwent CABG, whereas after CABG only two patients required additional myocardial revascularisation. There was no significant difference in the overall mortality between both groups; the survival rate after 12 and 24 months was 95% and 82% after PTCA and 93% and 86% after CABG, respectively. Condition: Although patients receiving CABG had a more severe coronary artery disease the overall mortality was comparable and clinical and functional outcome was improved compared to patients after coronary angioplasty. This revised version was published online in June 2006 with corrections to the Cover Date.     

Coronary artery bypass grafting (CABG) after initially successful percutaneous transluminal coronary angioplasty (PTCA): a review of 17 years experience.

OBJECTIVE: Patients who undergo successful percutaneous transluminal coronary angioplasty (PTCA) may subsequently require operative myocardial revascularization. This review examines whether prior successful PTCA alters outcomes following subsequent coronary artery bypass grafting (CABG). The costs of interventional cardiology procedures and definitive surgery were also examined. METHODS: From January 1981 through December 1997, 361 patients underwent CABG following initially successful PTCA (interval group). This group was compared with 11,909 patients who underwent CABG as the primary intervention for coronary artery disease (control group). RESULTS: The average time interval to CABG following initial PTCA was 13.7 months. The post-CABG myocardial infarction rate was 4% for patients in the interval group and 3% for patients in the control group. The 30-day mortality was similar for both patient groups (2%). For the interval group, the average cost of total interventional management was 24,220 dollars per patient. This included average costs of 13,873 dollars for CABG and 10,347 dollars for all preoperative interventional cardiology procedures. CONCLUSION: There is little doubt that PTCA procedures may provide successful myocardial revascularization. However, these procedures often need to be repeated over time and may serve only to delay coronary surgery, at substantial financial and personal cost.     

Acute coronary angiography after coronary artery bypass grafting

Objectives Coronary angiography is the golden standard when myocardial ischemia after CABG occurs. We summarize our experience of acute coronary angiography after CABG. Design All 4446 patients (mean age 68?±?9 years, 22% women) who underwent CABG 2007 to 2012 were included in this retrospective observational study. Incidence, indications, findings, measures of acute angiography after CABG was assessed. Outcome variables were compared between patients who underwent angiography and those who did not. Results Eighty-seven patients (2%) underwent acute coronary angiography. Patients undergoing angiography had ECG changes (92%), echocardiographic alterations (48%), hemodynamic instability (28%), angina (15%), and/or arrhythmia (13%). Positive findings were detected in 69% of the cases. Only ECG changes as indication for angiography had a moderate association with positive findings, but the precision increased if other sign(s) of ischemia were present. Thirty-day mortality (7% versus 2%, p?=?0.002) was higher and long-term-cumulative survival lower (77% versus 87% at five years, p?=?0.043) in angiography patients. Conclusions Acute angiography is a rare event after CABG. Postoperative myocardial ischemia leading to acute coronary angiography is associated with increased short-term and long-term mortality.     

The results and problems of reoperation for coronary artery disease]

In six hundred and six consecutive patients undergoing coronary artery bypass grafting (CABG) within the past 17 years (May 1974 to March 1991), repeated CABG were performed on 10 patients (1.65%). The main reasons for repeated CABG were graft failure (GF) in 8, progression of native disease (NP) in 5 and incomplete revascularization (IR) in 3 patients. The incidence of GF was high either within a half year or around 5 years after CABG. Although all patients survived from reoperation, four patients continued to have mild angina pectoris. When the recurrence of angina is noted after CABG, coronary arteriography and if necessary PTCA should be done as soon as possible. If a second surgery is inevitable, maximum utilization of arterial graft and accomplishment of complete revascularization are emphasized.     

PTCA of the left main stem following protective coronary artery bypass grafting

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 14 patients with significant left main stem stenosis following protective coronary artery bypass grafting (CABG). The procedure was successful in 13/14 patients (93%), achieving a decrease in mean diameter stenosis from 74% +/- 7% to 31% +/- 12% (P less than 0.01). Accordingly, the absolute stenosis diameter increased from 0.9 mm +/- 0.3 mm to 2.4 mm +/- 0.5 mm (P less than 0.01). Dissection of the left main stem artery and a transient significant fall of blood pressure each occurred in one patient. No other serious complications were noted. Eight of 13 patients (62%) with successful PTCA underwent control angiography. Restenosis had occurred in 3 of 8 patients (38%) with total occlusion of the left main stem in 1 patient. All bypass grafts were found to be patent at follow-up. Clinical evaluation in all 14 patients revealed no serious events (death, myocardial infarction, repeat revascularization procedure) during a mean follow-up period of 27 months (range 6-39 months). PTCA of the left main stem following CABG can be considered a relatively safe and effective procedure with a marked restenosis-rate but beyond that, an uncomplicated long-term follow-up.     

Internal mammary artery bypass: thirteen years of experience. Influence of angina and survival in 5125 patients.

Internal mammary artery (IMA) bypass to the anterior descending coronary artery (ADA) was performed in 5125 patients from January 1978 to December 1990. The average age of patients was 68 years; males accounted for 68% (3485 patients) and 82% (4203) were NYHA Class III. Left ventricular function was impaired (ejection fraction < 40%) in 68% (3485 patients). The average number of additional saphenous vein graft (SVG) per patient was 2.2. Operative mortality was 1.8%. Mediastinitis occurred in 51 patients (1.0%). Reoperation for bleeding was necessary in 56 patients (1.1%). Perioperative myocardial infarction was seen in 102 patients (2.0%) and neurological complications occurred in 51 patients (1%). Repeat coronary angiography was performed in 1414 patients (28%) and demonstrated a patency rate of 96% in IMA grafts and 75% in SVG grafts (p < 0.001). Survival at 13 years was 80% from all causes and 90% when non-cardiac deaths were excluded. Recurrence of angina occurred in 768 patients (15%) and reoperation or PTCA was performed in 61 (1.2%). During the same time period, 2345 patients underwent coronary artery bypass utilizing solely SVG. Survival at 13 years was 68% from all causes and 78% when non-cardiac deaths were excluded (p < 0.001). Recurrent angina was present in 727 patients (31%) (< 0.001). This data suggests that long-term probability of cumulative survival and occlusion free survival were significantly greater and the probability of recurrent angina and reoperative CABG and death from cardiac causes were significantly less in the IMA patients and should be the conduit of choice in coronary bypass surgery.     

Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease.

OBJECTIVE: Surgical treatment of thoracic aortic surgery in patients with coronary artery disease was investigated. METHODS: Between 1990 and April 2003, 330 patients underwent elective thoracic aortic surgery. Fifty-six patients who underwent aortic root reconstruction were excluded and 274 patients were examined. Fifty-four (20%) patients showed concomitant coronary artery disease. Ten had undergone coronary revascularization previously; and 3 underwent coronary revascularization [2 coronary artery bypass grafting (CABG), 1 percutaneous transluminal coronary angioplasty (PTCA)] before aortic surgery. Twenty-three patients underwent elective CABG simultaneously and 2 patients had additional coronary artery bypass because of cardiac ischemia during operation. The number of patients who underwent thoracic aortic surgery including Asc Ao+AVR was 2, hemi arch 1, total arch 15, distal arch 5, distal arch+LV aneurysmectomy 1, and thoracoabdominal Ao 1. Two patients underwent coronary revascularization with arterial grafts and the others with SVG grafts. RESULTS: There was one hospital death (4%). In patients without coronary bypass, 2 patients suffered cardiac ischemic events. CONCLUSION: Our thoracic aortic operations with concomitant CABG using SVG were overall successful. Our current strategies for thoracic aortic surgery in patients with concomitant coronary artery disease include conducting a dipyridamole myocardial perfusion-imaging test first in patients not at risk of coronary artery disease, and if the test is positive, coronary angiography is performed and aggressive coronary revascularization is conducted where possible.     

Combined valvular and coronary artery surgery

We report 14 consecutive patients who have undergone myocardial revascularization combined with valve surgery during 7 years (1983-1989). There were 7 males and 7 females with a mean age of 53.8 years. All patients had congestive heart failure and 7 had angina pectoris. Coronary angiography revealed single-vessel disease in 6 patients, double-vessel disease in 5, triple-vessel disease in 3. Mitral regurgitation was predominant in 5, aortic regurgitation in 5, mitral stenosis in 3 and aortic stenosis in 1. The indicated operations were: valve replacement in 12 and mitral anuloplasty in 2 with coronary artery bypass grafting (mean 1.6). One operative and 1 late death were seen in our series, however, NYHA functional class was improved from 3.4 to 1.7 postoperative. Postoperative evaluation by UCG showed good recovery of cardiac function (EF, MVcf, LVEDV, CI). No angina pectoris was evident in surviving patients, the quality of life was significantly improved.     

Coronary artery spasm after off-pump coronary artery bypass grafting

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.     

Indication for coronary revascularization in aortic surgery

In order to know how to treat the coronary artery disease in scheduled aortic surgery for aortic aneurysms, a prospective study started about ten years ago using routine coronary angiography (CAG). Thoracic aortic aneurysm (TAA): CAG was performed in 73 among 143 patients and 18 had significant coronary artery stenoses (CAD), 3 of whom had angina. Concomitant CABG was performed in 2 of 4 patients requiring coronary revascularization (CR) to prevent intraoperative myocardial ischemia. Complications due to CAD were experienced in the 2 patients without CR despite of angina, while patients without angina or with CR had no complication. Abdominal aortic aneurysm (AAA): Seventy six among 150 patients had CAG, and CAD was found in 38. CR was indicated to 5 of 7 patients with angina. Complications occurred in 2 patients who had not CR in spite of angina. Patients without angina had no complication. Conclusion: 1) Patients who had angina are at high risk for complications due to CAD. 2) Patients with angina and necessity of cardiac arrest during aneurysmectomy should have coronary revascularization prior to aneurysmectomy. 3) Patients without angina are at low risk for myocardial ischemia in the perioperative period of aortic surgery.     

Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass

BACKGROUND: The feasibility of complete revascularization on the beating heart without cardiopulmonary bypass (CPB) as compared with the standard operation with CPB in elective low-risk patients with multivessel disease has not been clearly demonstrated in a prospective trial. METHODS: Eighty selected low-risk patients were enrolled. In preoperative study with coronary angiography, the decision was made whether complete revascularization without CPB could be performed. Patients were randomly assigned to receive CABG either with (n = 40) or without CPB (n = 40). Randomization criteria were age, sex, and left ventricular ejection fraction. Completeness of revascularization as well as short- and mid-term clinical outcome in a 13.4 +/- 6.5 month follow-up period were monitored. RESULTS: Twenty-six of 40 (65%) patients undergoing CABG without CPB underwent complete revascularization. In 5 of these patients (12.5%) suitable vessels were discarded for technical reasons and 9 patients (22.5%) were switched to CABG with CPB owing to the deeply intramyocardial course of target vessels (n = 5) or to hemodynamic instability (n = 4). In the group of patients operated on with CPB, 34 of 40 patients (85%) received complete revascularization. In 6 patients (15%) suitable vessels were discarded for technical reasons. Mean number of bypass grafts was 3.1 +/- 0.8 with CPB and 2.6 +/- 0.5 without CPB (p = 0.043). Clinical outcome and hospital stay were comparable in both groups. No patient died during the study period. No myocardial infarction was observed. Three patients undergoing CABG without CPB underwent successful PTCA 3 months after surgery. CONCLUSIONS: CABG without the use of CPB is effective for complete revascularization in the majority of selected low-risk patients. Nevertheless, it has to be stated that the rate of incomplete revascularization in this early series of CABG without CPB is higher, and compromises the basic principle of complete revascularization.     

The role of transmyocardial laser revascularization in congestive heart failure

Transmyocardial laser revascularization (TMLR) has been approved as an indirect coronary revascularization measure through angiogenesis around created channels in patients who are not amenable to direct revascularization methods such as coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). TMLR is less invasive and there are no contraindications in terms of left ventricular function. Therefore all patients who have untreatable lesions by CABG or PTCA with reversible ischemia are candidates for TMLR therapy. In a Japanese clinical trial, improvement of left ventricular function associated with relief of persistent angina and improved perfusion was seen in 54% of patients. Significant reduction of operative risk in adjunctive TMLR (combination of TMLR with CABG) compared with isolated CABG has been also demonstrated in a randomized trial. These results indicate the usefulness of adjunctive TMLR in multivessel-disease patients with left ventricular dysfunction. Because TMLR is a simple and less-invasive technique, combined use of TMLR with off-pump CABG or MIDCAB is also an attractive revascularization strategy in ischemic cardiomyopathy patients.