The Comparison Study of Early and Midterm Clinical Outcome of Off-Pump versus On-Pump Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction (LVEF< or =35%) / 대한흉부외과학회지

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has been proven to result in less morbidity. The patients who have left ventricular dysfunction may have benefits by avoiding the adverse effects of the cardiopulmonary bypass. The present study compared early and midterm outcomes of off-pump versus on-pump coronary artery bypass grafting (On pump CABG) in patients with severe left ventricular dysfunction. MATERIAL AND METHOD: Ninety hundred forth six patients underwent isolated coronary artery bypass grafting by one surgeon between January 2001 and Febrary 2005. Data were collected in 100 patients who had left ventricular ejection fraction (LVEF) less than 35% (68 OPCAB; 32 On pump CABG). Mean age of patients were 62.9+/-9.0 years in OPCAB group and 63.8+/-8.0 years in On pump CABG group. We compared the preoperative risk factors and evaluated early and midterm outcomes. RESULT: In OPCAB and On pump CABG group, mean number of used grafts per patient were 2.75+/-0.72, 2.78+/-0.55 and mean number of distal anastomoses were 3.00+/-0.79, 3.16+/-0.72 respectively. There was one perioperative death in OPCAB group (1.5%). The operation time, ventilation time, ICU stay time, CK-MB on the first postoperative day, and occurrence rate of complications were significantly low in OPCAB group. Mean follow-up time was 26.6+/-12.8 months (4~54 months). Mean LVEF of OPCAB and On pump CABG group improved significantly from 27.1+/-4.5% to 40.7+/-13.0% and 26.9+/-5.4% to 33.3+/-13.7%. The 4-year actuarial survival rate of OPCAB and On pump CABG group were 92.2%, 88.3% and the 4-year freedom rates from cardiac death were 97.7%, 96.4% respectively. There were no significant differences between two groups in 4 year freedom rate from cardiac event and angina. CONCLUSION: OPCAB improves myocardial function and favors early and mid-term outcomes in patients with severe left ventricular dysfunction compared to On pump CABG group. Therefore, OPCAB is a preferable operative strategy even in patients with severe left ventricular dysfunction.

Clinical Results and Optimal Timing of OPCAB in Patients with Acute Myocardial Infarction / 대한흉부외과학회지

BACKGROUND: There are a lot of debates regarding the optimal timing of operation of acute myocardial infarction (AMI). Off pump coronary artery bypass grafting (OPCAB) has benefits by avoiding the adverse effects of the cardiopulmonary bypass, but its efficacy in AMI has not been confirmed yet. The purpose of this study is to evaluate retrospectively early and mid-term results of OPCAB in patients with AMI according to transmurality and timing of operation. MATERIAL AND METHOD: Data were collected in 126 AMI patients who underwent OPCAB between January 2002 and July 2005. Mean age of patients were 61.2 years. Male was 92 (73.0%) and female was 34 (27.2%). 106 patients (85.7%) had 3 vessel coronary artery disease or left main disease. Urgent or emergent operations were performed in 25 patients (19.8%). 72 patients (57.1%) had non-transmural myocardial infarction (group 1) and 52 patients (42.9%) had transmural myocardial infarction (group 2). The incidence of cardiogenic shock and insertion of intra-aortic balloon pump (IABP) was higher in group 2. The time between occurrence of AMI and operation was divided in 4 subgroups ( 8 days). OPCAB was performed a mean of 5.3+/-7.1 days after AMI in total, which was 4.2+/-5.9 days in group 1, and 6.6+/-8.3 days in group 2. RESULT: Mean distal anastomoses were 3.21 and postoperative IABP was inserted in 3 patients. There was 1 perioperative death in group 1 due to low cardiac output syndrome, but no perioperative new MI occurred in this study. There was no difference in postoperative major complication between two groups and according to the timing of operation. Mean follow-up time was 21.3 months (4~42 months). The 42 months actuarial survival rate was 94.9+/-2.4%, which was 91.4+/-4.7% in group 1 and 98.0+/-2.0% in group 2 (p=0.26). The 42 months freedom rate from cardiac death was 97.6+/-1.4% which was 97.0+/-2.0% in group 1 and 98.0+/-2.0% in group 2 (p=0.74). The 42 months freedom rate from cardiac event was 95.4+/-2.0% which was 94.8+/-2.9% in group 1 and 95.9+/-2.9% in group 2 (p=0.89). CONCLUSION: OPCAB in AMI not only reduces morbidity but also favors hospital outcomes irrespective of timing of operation. The transmurality of myocardial infarction did not affect the surgical and midterm outcomes of OPCAB. Therefore, there may be no need to delay the surgical off-pump revascularization of the patients with AMI if surgical revascularization is indicated.

Death on the General Wards after Discharge from ICU / 대한마취과학회지

BACKGROUND: Intensive care units (ICUs) provide a service for patients with potentially recoverable disease who might potentially benefit from closer observation and treatment. However, a number of patients who are successfully discharged from ICU subsequently die during their hospital admission. The aim of this study was to identify the incidence and characteristics of these deaths in general wards after discharge from ICUs. METHODS: Patients who were admitted to our ICU were classified in the following manner; Group 1, patients who survived to hospital discharge; Group 2, patients who died in the ICU; Group 3, patients who died in general wards after discharge from the ICU. Data was collected and patients age, sex, main diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II scores on the admission, and number of days in the ICU were compared. RESULTS: 1498 consecutive patients were admitted to the general ICU, and 1339 patients were discharged alive from hospital, 114 patients died in the ICU and 45 patients died during their post ICU hospital stay. 28% of the deaths after intensive care occurred in general wards before discharge from hospital. Among those patients who died in general wards, 7 (15.5%) were expected to survive. 29 (64%) had been withdrawn from sustained therapy before discharge from the ICU. CONCLUSIONS: Although some deaths following ICU discharge were inevitable, others were unexpected, and may have been preventable.

Can Ketamine Substitute for Fentanyl in Gynecologic Cone Biopsy Anesthesia? / 대한마취과학회지

BACKGROUND: In a gynecologic cone biopsy, fentanyl is commonly used with propofol for its analgesic effect, but it has many side effects, such as bradycardia, respiratory depression and hypotension. A subanesthetic dose of ketamine has an analgesic effect and minimal cardiovascular effects. We wanted to know whether ketamine can be safely used with propofol in a gynecologic cone biopsy instead of fentanyl. METHODS: Forty woman patients were randomly allocated to two groups. All patients were anesthesized with a propofol infusion. Fentanyl 1mug/kg IV was injected 2 minutes before LMA (laryngeal mask airway) insertion in group I, ketamine 0.25 mg/kg IV was injected also in group II. Blood pressure and heart rate were measured before fentanyl or ketamine injection, 1 minute, 3 minutes and 5 minutes after LMA insertion, and during the operation. A numerical rating scale (NRS) for pain and other side effects were checked for 24 hours after the operation. RESULTS: There were no significant differences between the two groups in blood pressure, heart rate, NRS and side effects, but a more stable systolic blood pressure in the ketamine group occured. CONCLUSIONS: For a gynecologic cone biopsy, propofol anesthesia combined with fentanyl or ketamine was not different for stable cardiovascular results, postoperative pain relief and side effects. Therefore, ketamine as an analgesic combined with propofol could replace fentanyl in gynecologic cone biopsy anesthesia.