Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications

We have performed a retrospective analysis of the peri-operative course of 218 consecutive patients who underwent routine coronary artery bypass graft surgery in this institution. All patients received a standardised general anaesthetic using target-controlled infusions of alfentanil and propofol. One hundred patients also received thoracic epidural anaesthesia with bupivacaine and clonidine, started before surgery and continued for 5 days after surgery. The remaining 118 patients received target-controlled infusion of alfentanil for analgesia for the first 24 h after surgery, followed by intravenous patient-controlled morphine analgesia for a further 48 h. Using computerised patient medical records, we analysed the frequency of respiratory, neurological, renal, gastrointestinal, haematological and cardiovascular complications in these two groups. New arrhythmias requiring treatment occurred in 18% of the thoracic epidural anaesthesia group of patients compared with 32% of the general anaesthesia group (p = 0.02). There was also a trend towards a reduced incidence of respiratory complications in the thoracic epidural anaesthesia group. The time to tracheal extubation was decreased in the epidural group, with the tracheas of 21% of the patients being extubated immediately after surgery compared with 2% in the general anaesthesia group (p < 0.001). There were no serious neurological problems resulting from the use of thoracic epidural analgesia.     

Efficacy of epidural analgesia in minimally invasive direct coronary artery bypass surgery

Minimally invasive direct coronary artery bypass surgery (MIDCAB), coronary bypass grafting with small thoracotomy using no cardiopulmonary bypass (CPB), became popular recently. To attenuate perioperative stress-response, we used epidural analgesia (EPI) with general anesthesia for MIDCAB operation. In this study, we compared retrospectively 11 cases of MIDCAB managed with EPI [ED (+)], and 14 cases of MIDCAB anesthetized without using EPI [ED (-)], concerning extubation time, ICU stay, hospital stay and perioperative complications. The mean time from cessation of general anesthesia to extubation was significantly shorter in ED (+) patients (0.5 hours) when compared to ED (-) patients (18.2 hours). Mean periods of ICU stay and hospital stay were, also, shorter in ED (+) patients (2.1 days, 30.5 days, respectively) when compared to ED (-) (4.3 days, 45.1 days, respectively) patients. We experienced ventricular tachycardia in three patients of ED (-). No major complication occurred in ED (+) patients. These results suggest that EPI shortened extubation time, ICU and hospital stay for MIDCAB patients.     

Multicomponent intravenous and epidural anesthesia in aorto-coronary bypass surgery

The influence of epidural anesthesia (CEA) on clinical manifestations, cortisole and adrenocorticotropic hormone (ACTH) level, central hemodynamic values during aorto-coronary bypass surgery (ACBS) in 56 patients aged 42-68 years with preserved functional capacity of the myocardium was studied. Catheterisation of the epidural space was carried out in the evening before the operation according to the standard method at the level of T4-T5 with the use of disposable epidural set. During the procedure before perfusion 2% solution of lidocaine 3.8 +/- 0.2 mg/kg was introduced in epidural space (taking into account test-dose) as a bolus in 3-4 motions. The dose of local anesthetics for infusion was selected separately for each individual case with due regard for hemodynamic values. During artificial circulation additionally local anesthetic was introduced as a bolus, the dose being 4.7 +/- 0.8 mg/kg. At the end of the operation morphine (0.061 +/- 0.001 mg/kg) was introduced. It was established that combined application of intravenous and epidural anesthesia represents highly effective method of anesthesia in aorto-coronary bypass surgery. According to clinical course data, cortisone and ACTH blood contents and hemodynamic parameters, EA provides adequate anesthesia, promotes stabilization of hemodynamic values and creates functionally more advantageous conditions for the myocardium in patients with CHD during aorto-coronary bypass operation. Anesthesiologic aid with the use of EA promotes reduction of intravenous anesthetics expenditure, earlier waking up of the patients in postoperative period and decrease in duration of postoperative artificial lung ventilation.     

A case of coronary artery bypass grafting for single coronary artery complicated by angina pectoris

A case of coronary artery bypass grafting (CABG) for single coronary artery complicated by angina pectoris (AP) was reported. The patient was a 74-year-old male, complained of anginal discomforts. His single coronary artery originated in left coronary sinus, bifurcated to the left anterior descending artery (LAD) and the circumflex artery (CX), and then, an abnormal communicating branch, passing in front of the right ventricular outflow, was branched from the proximal region of LAD; it showed a route corresponding to the proximal region of the right coronary artery (RCA). The distal region of RCA and the posterior descending artery were angiographed in continuity from CX. Other findings included 75%-stenosis at LAD-#6 and 90%-stenosis at CX-#13. Using two saphenous vein grafts, CABG operation was carried out on those regions at LAD-#7 and distal CX corresponding to #3 normally. Postoperatively, anginal discomforts disappeared, and favorable results were obtained.     

Harmonic scalpel in coronary artery bypass surgery

The startup performance of medical linear accelerators is of increasing importance for modern radiotherapy techniques. The traveling wave-type linear accelerator of the SL series of Philips (now Elekta Oncology Systems) has been modified in its flight tube design to meet this goal of a fast rise time of the radiation field. The new slitless flight tube combined with a redesigned gun servo electronic now achieves start up times of the radiation comparable with those of a standing wave linear accelerator (Siemens Mevatron) according to our measurements.     

The gastroepiploic artery graft in coronary artery bypass surgery

From March 1986 to October 1989, 91 patients underwent CABG using the right gastroepiploic artery (GEA) at Osaka Medical College and Mitsui Memorial Hospital. Including 14 females, the mean age was 57.9 years old ranged from 34 to 73 years old. Triple vessel disease and left main disease occupied over 90% of the patients. There were 5 emergency operations and 6 reoperations. Associated serious diseases were; renal failure with hemodialysis in 2 pts., familial hyperlipidemia in 5 pts., severe atherosclerotic ascending aorta in 8 pts., arteriosclerosis obliterance in 3 pts., and each one of abdominal aortic aneurysm and idiopathic thrombocytopenic purpura. The internal thoracic artery (ITA) graft was concomitantly utilized in 96% of the patients. Single ITA in 60 pts., double ITA in 23 pts. and sequential ITA in 5 patients. Saphenous vein graft was used in 58 patients and remaining 33 patients were operated without leg wound. The mean number of distal anastomoses was 3.3 ranged from 1 to 5, and the mean number of arterial grafts was 2.5 ranged from 1 to 4. The mean aortic cross clamp time and cardiopulmonary bypass time was 62.8 minutes and 113.6 minutes, respectively. Sites of GEA anastomosis were; 4 anterior descending, 3 diagonal, 11 circumflex and 73 right coronary arteries. There were 86 in situ grafts mostly for the right coronary arteries, and remaining 5 GEAs were used as a free graft to bypass the left coronary arteries. On the contrary, ITA was used to bypass the left coronary artery system preferentially. There was 3 combined procedures; splenectomy, abdominal aorta replacement, and ascending aorta to bifemoral artery bypass in each one patients. Three patients including one emergency case died within 30 days after surgery. Two were cardiac and one was renal failure. Other 2 patients died of stroke at late period. New Q wave infarction was noted in 2 patients. Relief of angina was obtained in 98% of survivors. The patency rate of the GEA graft was 97% in 61 grafts restudied within 6 postoperative months, which was identical with that of the ITA graft, that is 97% of 76 grafts. In conclusion, the GEA has several advantages as a coronary artery bypass graft such as similarity in size to the coronary artery, rare arteriosclerosis, feasibility of in situ graft, and no gastric complication. Its flow capacity is studying now and favourable results are being obtained. The final problem, its long term patency, will be resolved in future. GEA is a promising conduit for the coronary bypass surgery.     

Survival 15 to 20 years after coronary bypass surgery for angina

OBJECTIVES: The aim of this study was to determine the 15- to 20-year outcome of coronary bypass surgery in patients with angina. BACKGROUND: Coronary bypass surgery has been performed for > 20 years; we need to know the expected outcome of a very long-term follow-up. METHODS: Using actuarial techniques, we determined the outcome of coronary bypass surgery performed for chronic stable and unstable angina in 7,529 patients from 1969 to 1988. RESULTS: The 5-, 10-, 15- and 20-year survival rates (mean +/- SE) were 88 +/- 1, 73 +/- 1, 53 +/- 1 and 38 +/- 3%, respectively, for the whole group. Compared with patients operated on in 1974 to 1988 (n = 7,026), patients operated on in 1969 to 1973 (n = 503) were younger and had less coronary artery disease but had a higher operative mortality rate and a shorter long-term survival time; 15- and 20-year survival of the 1969 to 1973 cohort was 47 +/- 2% and 33 +/- 3%, respectively. The 1974 to 1988 cohort of patients had a 2.1% operative mortality rate and a 10- and 15-year survival probability of 74 +/- 1% and 55 +/- 2%, respectively. For 2,128 patients with "normal" left ventricular function, the 10- and 15-year survival probability was 82 +/- 1% and 64 +/- 3%, respectively, and for 2,413 patients with "abnormal" left ventricular function, it was 66 +/- 1% and 47 +/- 3%, respectively (p < 0.0001); for men it was 74 +/- 1% and 56 +/- 2%, respectively, and for women, 70 +/- 2% and 52 +/- 5%, respectively, p < 0.05. The actuarial percentages of reoperation and myocardial infarction at 15 years were 33 +/- 2% and 26 +/- 2%, respectively; these values did not differ significantly between men and women. There was a significant (p < 0.001) difference between men and women in angina status; 81% of the men versus 74% of the women had no angina or mild angina at the most recent follow-up study. CONCLUSIONS: Coronary bypass surgery is an effective form of therapy for angina (for 15 to 20 years) in both men and women.     

Landmarks in the development of coronary artery bypass surgery

Genetic linkage maps have been produced for a wide range of organisms during the last decade, thanks to the increasing availability of molecular markers. The use of microsatellites (or Simple Sequence Repeats, SSRs) as genetic markers has led to the construction of "second-generation" genetic maps for humans, mouse and other organisms of major importance. We constructed a second-generation single-tree genetic linkage map of Norway spruce (Picea abies K.) using a panel of 72 haploid megagametophytes with a total of 447 segregating bands [366 Amplified Fragment Length Polymorphisms (AFLPs), 20 Selective Amplification of Microsatellite Polymorphic Loci (SAMPLs) and 61 SSRs, each single band being treated initially as a dominant marker]. Four hundred and thirteen markers were mapped in 29 linkage groups (including triplets and doublets) covering a genetic length of 2198.3 cM, which represents 77.4% of the estimated genome length of Picea abies (approximately 2839 cM). The map is still far from coalescing into the expected 12 chromosomal linkage groups of Norway spruce (2n = 2x = 24). A possible explanation for this comes from the observed non-random distribution of markers in the framework map. Thirty-eight SSR marker loci could be mapped onto 19 linkage groups. This set of highly informative Sequence Tagged Sites (STSs) can be used in many aspects of genetic analysis of forest trees, such as marker-assisted selection, QTL mapping, positional cloning, gene flow analysis, mating system analysis and genetic diversity studies.     

A case of coronary artery bypass grafting for effort angina in a patient with post skin grafting for an extramammary Paget's disease

The extramammary Paget's disease of anogenital area is rare, and is seen as a precancerous lesion or carcinoma in situ. In most cases, surgical treatment including dissection of regional lymph nodes, skin resection and grafting should be considered first. A 74-year-old male suffered from effort angina and underwent triple coronary artery bypass grafting (CABG) including saphenous vein graft (SVG) harvested from right lower leg. Five years previously he underwent skin grafting for extramammary Paget's disease of both inguinal areas and the perineal area. The postoperative course was uneventful and he was discharged 23 days after the CABG operation. Extramammary Paget's disease is localized in epidermis for years and there has been no report of direct invasion into vessels. Therefore, there appears to be no reason not to use an SVG if there is no luminal thrombus or occlusion.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

Endoscopic harvesting of the radial artery as a coronary artery bypass graft

With an endoscopic approach we harvested the radial artery as a coronary artery bypass graft, using two transverse 2-cm incisions in the forearm. There were no complications in the forearm and hand. The short-term results of the radial artery graft were good.     

Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery

OBJECTIVE: The purpose of this study was to evaluate morbidity and mortality in reoperative coronary artery bypass surgery using the New York State database. METHODS: Patients undergoing reoperative coronary artery bypass between January-1995 and December 1996 were included. Patients were operated using cardiopulmonary bypass (CPB group, n = 184) or without cardiopulmonary bypass (non-CPB group, n = 105) by surgeon preference. Groups were compared for preoperative risk factors, postoperative mortality and major complications. RESULTS: Crude mortality was lower in the non-CPB group, despite a higher expected mortality, resulting in a risk-adjusted mortality of 1.3% versus 2.7% for the CPB group (NS). Of non-CPB patients, 91.4% were without complications, while only 72.1% of CPB patients (P < 0.0001) were complication-free. Major complications were significantly reduced in non-CPB patients compared to CPB patients: stroke 0% versus 3.8% (P < 0.04), cardiovascular complications 4.8% versus 15.8% (P < 0.005), other major complications 1.9% versus 10.4% (P < 0.007). Postoperative IABP support was needed in 1.9% of the non-CPB group patients and in 14.2% of the CPB group (P < 0.0007). CONCLUSIONS: The main object of reoperative CABG is to relieve symptoms, since the survival benefit of the procedure has not been demonstrated. Performance of reoperative coronary artery bypass surgery without cardiopulmonary bypass significantly reduces morbidity. We conclude that cardiopulmonary bypass should be avoided whenever possible in reoperative coronary bypass surgery.     

What is a safe waiting time for coronary artery bypass surgery?

To determine the factors that influenced doctors' prioritization and decisions on safe waiting time for coronary artery bypass surgery, 50 'paper patients', based on a random sample of cases who actually had surgery, were assessed by 33 clinicians. We used linear regression models to reflect the impact of clinical and non-clinical 'cues' on safe waiting time and priority decisions. The benefits of surgery tended to be over-estimated. For example, the average perceived gain in life expectancy for patients with left main-stem disease was 6.74 years. However, models incorporating only the perceptions of benefit as independent variables (i.e. the anticipated symptom reduction, MI risk reduction and life expectancy extension), had only modest explanatory power (mean R2 was 0.55 for safe waiting time, and 0.56 for priority decisions). Models which incorporated perceptions of benefit and the cases' clinical and non-clinical characteristics had generally much higher explanatory power (mean R2, 0.83 and 0.86, respectively). Lifestyle and demographic variables had much less impact on the doctors' judgements than the major clinical cues of angina severity and left main-stem stenosis. Demographic and lifestyle cues had different impacts on safe waiting time and priority for about 25% of doctors.     

The inferior epigastric artery as a coronary artery bypass graft]

From January 1992 through December 1993, 31 patients underwent myocardial revascularization with the inferior epigastric artery (IEA) graft. There were one emergency case and four coronary reoperation cases. IEA grafts were taken down through the left side paramedian incision and dilated with papaverine hydrochloride solution. The distal anastomoses were made to left anterior descending (3 cases), diagonal (14 cases), obtuse marginal (9 cases), postero-lateral (I case) and right coronary artery (4 cases). The proximal anastomoses were made to the aorta (22 cases), the hood of a new vein graft (4 cases) and the hood of an old vein graft (4 cases). When IEA was not long enough to reach the ascending aorta, it was anastomosed to the internal thoracic artery (2 cases) or the gastroepiploic artery (1 case) graft. There was one hospital death, and early patency rate (within one month) was 90% (19/21). The postoperative angiography performed at 1.3 years or 2 years showed excellent IEA graft patency. These results suggested that the IEA is suitable as a coronary artery bypass graft. Further long-term patency must be evaluated.     

Aprotinin in patients having coronary artery bypass graft surgery

Any therapy must have a benefit and a risk. The benefit of aprotinin therapy in reducing bleeding is well known. Data presented over the past 12 months have confirmed this efficacy and the superiority and consistency of aprotinin therapy in direct comparison with other pharmacologic (desmopressin, tranexamic acid) and physical (administration of fresh platelet concentrate) interventions. The debate has now changed to focus on issues of the safety of this agent. In particular, concerns have been expressed as to the effect of this agent on renal function, thrombotic potential (and thus graft patency), and adverse reactions on a second exposure. Most recent reports show plasma creatinine concentrations are higher in treated than in nontreated patients on the 3rd or 4th postoperative day. The concentrations reached were not outside the clinical range, and there were no clinical sequelae of this biochemical abnormality. Focused studies have shown no effect of the use of aprotinin therapy on early graft patency or the incidence of thromboembolic complications. The reporting of hypersensitivity reactions following aprotinin administration suggests that the incidence is not different to other agents used in open heart surgery. Three reports of fatal or near-fatal cardiovascular collapse associated with the use of aprotinin followed the apparently inappropriate administration of the agent.     

Outcomes of coronary artery bypass surgery in elderly people

The role of non-invasive nocturnal domiciliary ventilation (NNV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnia is still discussed. The aims of this study were to evaluate the long-term survival, the clinical effectiveness and side-effects of NNV in these patients. Forty-nine stable hypercapnic COPD patients on long-term oxygen therapy (LTOT) were assigned to two groups: in Group 1, 28 patients performed NNV by pressure support modality in addition to LTOT; in Group 2, 21 patients continued their usual LTOT regimen. Treatment was assigned according to the compliance to NNV, after an in hospital period. Mortality rate, hospital stay (HS) and ICU admissions (IA) were recorded in the two groups. HS and IA were compared to those recorded in a similar period of follow-back. Lung and respiratory muscle function, dyspnoea, and exercise capacity (by 6-min walk test) were evaluated baseline and every 3-6 months up to 3 yr. Mean follow-up time was 35 +/- 7 months. Mortality rate was not different between the two groups: 16, 33, 46% and 13, 28, 50% at 1, 2 and 3 yr in Groups 1 and 2 respectively. Lung and respiratory muscle function did not significantly change over time. A significant increase in 6-min walk test (from 245 +/- 78 to 250 +/- 88, 291 +/- 75, 284 +/- 89 m after 1, 2 and 3 yr respectively, P < 0.01) was observed only in patients undergoing NNV. In comparison to the follow back HS significantly decreased in both groups (from 37 +/- 29 to 15 +/- 12 and from 32 +/- 18 to 17 +/- 11 days/pt/yr in Groups 1 and 2 respectively, P < 0.001) whereas IA significantly decreased only in patients performing also NNV (from 1.0 +/- 0.7 to 0.2 +/- 0.3/pt/yr, P < 0.0001). Addition of NNV by pressure support modality to LTOT does not improve long term survival but significantly reduces ICU admissions and improves exercise capacity in severe COPD with hypercapnia.     

Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting

BACKGROUND: Epidemiologic studies have shown dietary antioxidants to be inversely correlated with ischemic heart disease. OBJECTIVE: We investigated whether dietary beta-carotene, vitamin C, and vitamin E were related to the risk of myocardial infarction (MI) in an elderly population. DESIGN: The study sample consisted of 4802 participants of the Rotterdam Study aged 55-95 y who were free of MI at baseline and for whom dietary data assessed by a semiquantitative food frequency questionnaire were available. During a 4-y follow-up period, 124 subjects had an MI. The association between energy-adjusted beta-carotene, vitamin C, and vitamin E intakes and risk of MI was examined by multivariate logistic regression. RESULTS: Risk of MI for the highest compared with the lowest tertile of beta-carotene intake was 0.55 (95% CI: 0.34, 0.83; P for trend = 0.013), adjusted for age, sex, body mass index, pack-years, income, education, alcohol intake, energy-adjusted intakes of vitamin C and E, and use of antioxidative vitamin supplements. When beta-carotene intakes from supplements were considered, the inverse relation with risk of MI was slightly more pronounced. Stratification by smoking status indicated that the association was most evident in current and former smokers. No association with risk of MI was observed for dietary vitamin C and vitamin E. CONCLUSION: The results of this observational study in the elderly population of the Rotterdam Study support the hypothesis that high dietary beta-carotene intakes may protect against cardiovascular disease. We did not observe an association between vitamin C or vitamin E and MI.     

Long lasting epidural anesthesia for a morbidly obese patient

Blood pressure (BP) differences between two consecutive 24-h monitoring periods (P1, P2) were analyzed in 159 hospitalized pregnant women. Reproducibility index, or twice the standard deviation of differences between individual systolic and diastolic means, was better for 24-h (7.8 and 5.8) and daytime (8.7 and 6.3) than for nighttime (12.2 and 9.7) BP means. It did not depend on BP level or gestation week. Alert reaction to monitoring procedure increased BP only in the first 2 h of P1. The high overall reproducibility of ambulatory BP in pregnancy supports the expanding use of the technique also in this condition.