Factors affecting patency of internal thoracic artery graft: clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002.

OBJECTIVE: The purpose is to define factors influencing long-term patency of the internal thoracic artery (ITA) to optimize the operative strategy. METHODS: 1482 left internal thoracic artery (LITA) and 636 right internal thoracic artery (RITA) symptom-directed angiograms were studied in 1434 patients. Data were prospectively collected from patients who had primary coronary artery bypass surgery during the period 1982-2002. The mean age of patients was 59 years; 85% were male. The mean period from operation to re-angiogram was 80 months. LITA was grafted to left anterior descending coronary artery (LAD) in 82% of cases, RITA to right coronary artery (RCA) in 40% and circumflex artery in 35% of cases. Graft failure was defined as > or =80% stenosis. RESULTS: 96.3% of LITA and 88.1% of RITA grafts were patent. No patient variables were significantly associated with graft patency (age, gender, diabetes, hypertension, LVEF, NYHA, AMI). Target coronary artery was associated with patency of both LITA and RITA grafts with maximum patency when grafted to LAD (P = 0.02) RITA had the worst patency to RCA, patency for the left system was identical to LITA. Proximal anastomosis to aorta (free RITA) had significantly better patency when compared with in situ RITA to RCA system (P = 0.005) while similar patency when grafted to left system. ITA diameter and target artery diameter were not associated with graft patency. Recent operations had better RITA patency (P = 0.03). The interval from operation to angiogram was not associated with ITA patency (96% patency for LITA and 88% patency for RITA, remained stable when studied at <1, 1-4, 5-9, 10-14 and >15 years). CONCLUSIONS: Even in a patient cohort that had adverse symptoms, excellent LITA and RITA patency was achieved which almost remained constant through all time intervals studied.     

Upper extremity deep vein thrombosis after radial artery harvesting

A 47-year-old diabetic man with unstable angina underwent coronary bypass surgery using bilateral radial arteries and left internal thoracic artery. After surgery, the patient suffered from severe right arm pain and swelling without any bleeding. The postoperative immediate digital subtraction angiogram detected thrombotic occlusion of the right axillary vein. We report here a rare case of deep vein thombosis related to radial artery harvesting.     

Coronary artery bypass surgery in undiagnosed traumatic pericardial rupture--25 years later

A 55-year-old man was electively admitted for coronary artery bypass surgery. His admission chest X-ray showed an abnormal cardiac silhouette with complete leftward displacement. He had a past history of blunt thoracic trauma due to a motor vehicle accident treated conservatively. We present our findings and surgical difficulty during an operation on a patient with a previously undiagnosed pericardial rupture. This is the first reported case of its kind in the cardiac surgical literature.     

Initial twelve months experience and analysis for 2001-2002 from the Australasian Society of Cardiac and Thoracic Surgeons--Victorian database project

The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) have established a database for the collection and analysis of the results of cardiac surgery in Australia and New Zealand. Initially data has been collected only in Victoria public hospitals. This report covers the first 12 months of data collection from 1st August 2001 to 1st July 2002. BACKGROUND: Whilst cardiac surgical performance in Australia is considered to be of a high standard equivalent to other developed countries, there is currently no systematic approach to data collection in order to provide performance indicators and benchmarks. The development of an Australasian cardiac surgical database and performance indicators will enable benchmarking and comparison with international standards which should lead to performance improvements. METHODS: A database definition set and standardised data collection form was developed by the ASCTS for all participating cardiac surgery units in public hospitals in Victoria. Opt-off consent for subject inclusion in the database was approved by each participating institutional ethics review committee. An electronic database and reporting application was developed. Data included in this analysis is from the initial 12 months collection from all hospitals participating in the project from 1st August 2001 to 31st July 2002. RESULTS: Overall, there were 2982 procedures performed in this period of which 2969 had sufficient data to be included in this analysis (99.5%). The majority of procedures 2017 (68%) being undertaken were isolated coronary artery bypass surgery (CABG). The mean age of all subjects undergoing procedures was 65 years (range: 18-91 years) and 70% were male. 64% of all procedures were elective and 6.1% emergency or salvage. Median post-procedure length of hospital stay for all procedures was 6.0 days and intensive care unit (ICU) stay was 23.0h. Re-operation for haemorrhage occurred in 2.1% of all cases and deep sternal infection in 0.4% of all cases. Crude 30-day operative mortality was 3.6% for all procedures; 2.1% for isolated CABG, 3.6% for valve procedures, 5.2% for valve and CABG and 11.4% for other cardiac surgical procedures. Mortality rates increased from 1.8% for elective procedures to 4.1% for urgent and 24.6% for emergency or salvage operations. In comparison to international figures from the USA and UK, mortality rates following isolated CABG were lower whilst average length of hospital stay post-procedure was higher. CONCLUSION: The ASCTS database project is now well established and the electronic database and reporting module is in operation in all participating sites. The risk-adjusted isolated operative mortality suggests cardiac surgical performance in Victoria compares well with international standards. As the database develops, local risk-adjustment models for mortality and morbidity for each procedure will be developed to enable appropriate between hospital comparisons.     

Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up

OBJECTIVE: To compare the safety, availability, and long-term sequelae of percutaneous vs. surgical tracheostomy. DESIGN: Prospective, randomized, controlled study. SETTING: Combined medical/surgical intensive care unit in a tertiary referral hospital. PATIENTS: Two hundred critically ill mechanically ventilated patients who required tracheostomy. INTERVENTIONS: Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the aggregate incidence of predefined moderate or severe complications. The secondary outcome measures were the incidence of each of the components of the primary outcome. Long-term follow-up included clinical assessment, flow volume loops, and bronchoscopy. Both groups were well matched for age, gender, admission Acute Physiology and Chronic Health Evaluation II score, period of endotracheal intubation, reason for intubation, and admission diagnosis. There was no statistical difference between groups for the primary outcome. Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient (p = .2). Postoperative infection (p = .044) and cosmetic sequelae (p = .08) were more common in surgical tracheostomy patients. There was a shorter delay from randomization to percutaneous tracheostomy vs. surgical tracheostomy (p = .006). Long-term follow-up revealed no complications in either group. CONCLUSIONS: Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced, skilled practitioners.     

What factors influence the results of coronary artery bypass grafting in aged patients?

AIM: Early and late results were studied in order to improve the indication for coronary artery bypass grafting (CABG) and to enhance RESULTS: METHODS: A total of 1 973 patients aged 70 years and older who had undergone isolated CABG were studied. Elective operations (EL) were performed in 1 716 patients and 257 patients underwent urgent or emergency operations (UR/EM). Patients were divided into two groups; 104 patients aged 80 years and older (Oct. Group) and 1 869 patients of septuagenarians (Sept. Group). There were no differences between the groups in the number of diseased vessels. RESULTS: Total operative mortality rates in the Oct. and the Sept. groups were 7% and 4%, respectively. The operative mortality of elective surgery was 4% in both groups. The operative mortality of UR/EM CABG was significantly higher in the Oct. group than in the Sept. group (21% vs 6%). Operative mortality was significantly higher in patients with preoperative poor (<49%) left ventricular ejection fraction (LVEF) than in patients with higher (>50%) LVEF (6% vs 3%). Among preoperative risk factors, diabetes mellitus and peripheral vascular disease were significant contributory factors to operative death. In the follow-up study, 70% patients of the Oct. group and 72% patients of the Sept. group survived. Preoperative number of diseased vessels and number of CABG grafts did not influence the early and late RESULTS: CONCLUSION: Preoperative poor LVEF, diabetes mellitus and peripheral vascular disease were significant contributory factors to operative death. When feasible, CABG in octogenarians should be performed electively.