A clinical study of preoperative prophylactic application of intra-aortic balloon pump in extreme high-risk patients undergoing coronary artery bypass grafting / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the clinical outcome between the intra-aortic balloon pump (IABP) inserted in the preoperative prophylactic condition and in the emergent condition for the patients with extreme high risks undergoing coronary artery bypass grafting (CABG).</p><p><b>METHODS</b>Totally 92 extreme high risk patients undergoing CABG combined with IABP supporting, whose European System for Cardiac Operative Risk Evaluation were equal or more than 12 points, some also undergoing surgical operations of myocardial infarction mechanical complications from January 2008 to June 2011, were analyzed retrospectively. According to the IABP established time, these patients were divided into two groups: preoperative group (57 cases) and passive group (35 cases). Items of comparison between two groups were the rate of mortality, myocardial infarction rate, severity of postoperative myocardial dysfunction and inotropic drug consumption quantity, IABP support time, respiratory support time, ICU stay time, renal function and IABP related complications.</p><p><b>RESULTS</b>Perioperative mortality and myocardial infarction rate in preoperative group (1.8%, 3.5%) were significant lower than those in passive group (11.4%, 17.1%) (χ(2) = 3.949, P = 0.047; χ(2) = 5.077, P = 0.024). Compared to passive group, the IABP support time, respiratory support time, and ICU stay time (t = 4.113-4.795); severity of postoperative myocardial dysfunction and inotropic drug consumption quantity, and renal dysfunction (χ(2) = 5.077-23.521) were decreased significantly in preoperative group (all P < 0.05). There were no significant difference in IABP related complications (P = 0.431).</p><p><b>CONCLUSIONS</b>For extreme high risk CABG patients, comparing to passive insertion of the IABP, preoperative prophylactic application of IABP shows the advantages in reducing perioperative mortality, myocardial infarction rate, inotropic drug consumption quantity, renal dysfunction, ICU stay time, respiratory support time and IABP support time.</p>

Surgery for left ventricular aneurysm after myocardial infarction: techniques selection and results assessment / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The most appropriate surgical approach for patients with post-infarction left ventricular (LV) aneurysm remains undetermined. We compared the efficacy of the linear versus patch repair techniques, and investigated the mid-term changes of LV geometry and cardiac function, for repair of LV aneurysms.</p><p><b>METHODS</b>We reviewed the records of 194 patients who had surgery for a post-infarction LV aneurysm between 1998 and 2010. Short-term and mid-term outcomes, including complications, cardiac function and mortality, were assessed. LV end-diastolic and systolic dimensions (LVEDD and LVESD), LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI) and LV ejection fraction (LVEF) were measured on pre-operative and follow-up echocardiography.</p><p><b>RESULTS</b>Overall in-hospital mortality was 4.12%, and major morbidity showed no significant differences between the two groups. Multivariate analysis identified preoperative left ventricular end diastolic pressure > 20 mmHg, low cardiac output and aortic clamping time > 2 hours as risk factors for early mortality. Follow-up revealed that LVEF improved from 37% pre-operation to 45% 12 months post-operation in the patch group (P = 0.008), and from 44% pre-operation to 40% 12 months postoperation in the linear group (P = 0.032). In contrast, the LVEDVI and LVESVI in the linear group were significantly reduced immediately after the operation, and increased again at follow-up. However, in the patch group, the LVEDVI and LVESVI were significantly reduced at follow-up. And there were significant differences in the correct value changes of LVEF and left ventricular remodeling between linear repair and patch groups.</p><p><b>CONCLUSIONS</b>Persistent reduction of LV dimensions after the patch repair procedure seems to be a procedure-related problem. The choice of the technique should be tailored on an individual basis and surgeon's preference. The patch remodeling technique results in a better LVEF improvement, further significant reductions in LV dimensions and volumes than does the linear repair technique. The results suggest that LV patch remodeling is a better surgical choice for patients with post-infarction LV aneurysm.</p>

The outcomes of restrictive mitral annuloplasty and coronary artery bypass grafting for ischemic mitral regurgitation and reverse left ventricular remodeling / 中华外科杂志

<p><b>OBJECTIVE</b>To retrospectively summarize and analyze the short and mid term follow-up outcomes of combined coronary artery bypass grafting (CABG) and restrictive mitral annuloplasty in curing ischemic cardiomyopathy and ischemic mitral regurgitation (IMR), and to study its effect on reverse left ventricular remodeling.</p><p><b>METHODS</b>From January 2000 to June 2008, 111 patients of coronary artery disease with moderate to severe IMR underwent combined CABG and restrictive mitral annuloplasty, downsizing by 1-2 ring sizes. There were 81 male and 30 female patients. The age ranged from 36 to 83 years with a mean of (63 ± 18) years. Preoperative transthoracic echocardiography showed minimal to moderate IMR in 7 cases, moderate to severe in 65 cases and severe in 39 cases. The left arterial diameter (LAD) was (58 ± 6) mm, left ventricular end-diastolic diameter (LVEDD) was (61 ± 8) mm, left ventricular ejection fraction (LVEF) was 46% ± 6%. Serial studies were performed to assess the survival rate, the extent of mitral regurgitation (MR), LVEF, the leaflet coaptation height, LAD, LVEDD, New York Heart Association (NYHA) functional class.</p><p><b>RESULTS</b>Hospital mortality was 2.7% (3 cases). Each case received an undersized ring. Intraoperative transesophageal echocardiography showed that no regurgitation in 69 cases, minimal in 34 cases, minimal to moderate in 5 cases, moderate to severe in 3 cases which received mitral valve replacement. The 3-, 12- and 24-month survival rate was 96.2%, 93.5% and 89.7% respectively. Mitral regurgitation grade decreased after the operative procedure (P < 0.01). LVEF increased from (46 ± 6)% to (53 ± 6)% (24 months follow-up) (P < 0.01). LAD decreased from (58 ± 6) mm to (46 ± 6) mm (24 months follow-up) (P < 0.01). LVEDD decreased from (61 ± 8) mm to (48 ± 10) mm (24 months follow-up) (P < 0.01). There was no significant decline of LVEDD in 18 cases (16.2%) whose preoperative mean LVEDD was (69 ± 9) mm. NYHA functional class improved after operative procedures (P < 0.01). At 24 months follow-up, 2 cases received valvular replacement.</p><p><b>CONCLUSIONS</b>Combined CABG and restrictive mitral annuloplasty is a feasible and effective treatment for IMR, the short and mid term outcomes are satisfactory, and a significant reduction of LVEDD and an increase of LVEF due to reverse ventricular remodeling were observed.</p>

The morphometry and eNOS expression of radial artery in elderly patients with coronary atherosclerotic heart disease / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the morphometry and endothelial nitric oxide synthase (eNOS) expression of radial artery (RA) between young and elderly patients with coronary atherosclerotic heart disease.</p><p><b>METHODS</b>From February 2008 to June 2009, 219 patients underwent coronary artery bypass grafting (CABG) with autologous RA, 57 patients aged beyond 70 years and 64 patients aged under 60 years. Before RA was harvested, a modified Allen test was routinely performed. If positive, RA would be further evaluated with Doppler ultrasound examination. In both groups RA was collected for HE staining to evaluate percentage of luminal narrowing (LN) and relationship between intima and media width at maximum intimal thickness (IMR). Immunofluorescence and Western blot were used to investigate the location and expression level of eNOS within the wall of RA.</p><p><b>RESULTS</b>Morphometry of RA in both young and elderly patients represented mild or moderate intimal hyperplasia, and medial calcification was not found. LN in elderly patients was (22 ± 6)%, while in young patients, it was (23 ± 6)%. IMR in elderly patients was 0.36 ± 0.21, while in young patients, it was 0.42 ± 0.19. There was no significant difference in both LN and IMR between two groups (P > 0.05). Immunofluorescence indicated RA in both groups revealed a high expression of eNOS in intima and media, particularly in the smooth muscle of media. The values of relative integrated optical density in elderly patients was 1.21 ± 0.13, while in young patients, it was 1.25 ± 0.12. Also there was no significant difference in the expression level of eNOS within the wall of RA (P > 0.05).</p><p><b>CONCLUSION</b>After preoperative assessment with modified Allen's test and Doppler analysis, RA used as graft in the elderly has similar quality and function with young patients, and it may lead to a high patency in long term.</p>

Experimental study on the option of antispasmodic drugs for radial artery in elderly patients with coronary atherosclerotic heart disease / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the relief effect of diltiazem, papaverine and nitroglycerin on radial artery spasm in elderly patients with coronary atherosclerotic heart disease.</p><p><b>METHODS</b>Sixty patients aged beyond 70 years underwent coronary artery bypass grafting (CABG) with autologous radial artery from July 2009 to March 2010. Redundant radial artery was collected and the relief function of different drugs was evaluated through "organ bath" technique in vitro. All the patients were randomly divided into 3 groups based on different antispasmodic drugs: diltiazem, papaverine and nitroglycerin. Thirty seconds free blood flow of radial artery and hemodynamic parameters (heart rate, mean arterial pressure and central venous pressure) were assessed before and after intra-radial administration of diltiazem, papaverine and nitroglycerin in vivo.</p><p><b>RESULTS</b>All three drugs could relieve radial artery spasm in different levels and the eventual relief rate was over 80%. Only nitroglycerin could relax radial artery completely, the relief capacity of nitroglycerin, diltiazem and papaverine decreased in order. There was no significant difference in the hemodynamic parameters before and after the injection. Blood flow of radial artery increased in nitroglycerin group [(42 ± 10) ml/30 s vs. (28 ± 7) ml/30 s, P < 0.05] while there was no significant difference in diltiazem [(23 ± 10) ml/30 s vs. (25 ± 8) ml/30 s, P > 0.05] and papaverine group [(25 ± 10) ml/30 s vs. (24 ± 9), P > 0.05].</p><p><b>CONCLUSIONS</b>Nitroglycerin could relieve vasospasm of radial artery effectively and increased blood flow. Nitroglycerin is the suitable antispasmodic drug for radial artery in the elderly patients with coronary atherosclerotic heart disease compare with diltiazem and papaverine.</p>

Impact of preoperative clopidogrel in coronary artery bypass grafting / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze and assess the impact of clopidogrel given preoperatively in coronary artery bypass grafting (CABG) surgery.</p><p><b>METHODS</b>From January 2005 to January 2007, 440 consecutive patients undergoing CABG surgery were divided into two groups: the clopidogrel group (with clopidogrel exposure in 5 days prior to surgery, n = 90) and the control group (without clopidogrel exposure > 5 days prior to surgery, n = 350). Patients undergoing emergency surgery because of failed percutaneous transluminal coronary angioplasty and cardiogenic shock, associated valvular surgery, redo-CABG were excluded. Patients who received aspirin and/or heparin treatment before surgery were included.</p><p><b>RESULTS</b>There was no significant difference in two groups regarding age, gender,diabetes mellitus and hypertension. Compared to the control group, patients in clopidogrel group had a higher prevalence of angina class III or IV (66.7% vs. 40.0%, P < 0.01), received more often revascularization within 48 h (41.1% vs. 14.3%, P = 0.02), and had received more frequently stenting (56.7% vs. 13.4%, P < 0.01). Chest tube drainage was significantly increased during the first 24 h following CABG in the clopidogrel group (800 ml vs. 350 ml, P < 0.01). Patients of the clopidogrel group also required more transfusion of packed red blood cells and fresh frozen plasma. Overall re-exploration rate because of bleeding was remarkably higher in the clopidogrel group (4.4% vs. 1.1%, P < 0.01).</p><p><b>CONCLUSIONS</b>Clopidogrel exposure in 5 days or less prior to CABG surgery significantly increases the risk of postoperative bleeding, the need for perioperative transfusion and the incidence of re-exploration. For the elective CABG patient, we suggest that the surgery should to be performed 5 days or more after clopidogrel exposure.</p>

Coronary endarterectomy and bypass grafting without cardiopulmonary bypass for patients with diffused coronary artery disease / 中华外科杂志

<p><b>OBJECTIVE</b>To review and summarize the early outcomes and clinical experience of coronary endarterectomy (CE) and bypass grafting without cardiopulmonary bypass for patients with diffused coronary artery disease.</p><p><b>METHODS</b>From May 2003 to May 2005, 53 patients with diffused coronary artery disease underwent CE and bypass grafting without cardiopulmonary bypass. There were 41 males and 12 females aged from 55 to 79 (mean 64 +/- 7) years old. 72% patients (38/53) were in Canadian Cardiac Society (CCS) angina class III and IV. 49% (26/53) had history of myocardial infarction. Coronary angiogram revealed that 3 cases had double vessels disease and, other 50 cases had triple vessels disease with 9 left main stem disease. The left ventricular ejection fraction (LVEF) ranged from 0.26 to 0.65 (0.52 +/- 0.17). Seventy endarterectomies were performed in 53 patients totally which included 38 in left anterior descending artery (LAD), 8 in circumflex artery and 24 in right coronary artery. Five cases received on-lay venous patch after CE in LAD and then grafted by internal mammary artery (IMA) on the patch. There were 53 left IMAs, 2 radial arteries, others were great saphenous veins, the mean number of grafts was 3.8 +/- 1.1 with index of completeness of revascularization (ICR) 1.03 +/- 0.07.</p><p><b>RESULTS</b>Intra-operative graft flow-meter was used to check the flow in the grafts before chest closure. There is no death in the group. Sixty-three (90%) out of 70 grafts after CE showed a satisfactory grafts flow intra-operatively. Two patients had peri-operative myocardial infarctions but neither had hemodynamic changes. All patients discharged uneventfully with mean hospital stay 9 days postoperatively. Forty-four patients had 6 to 29 months follow-up with no angina re-occurrence. Six patients had coronary angiogram 3 to 27 months postoperatively with all patent grafts to the CE coronaries.</p><p><b>CONCLUSION</b>CE and bypass grafting without cardiopulmonary bypass is technically feasible and can be performed safely in patients with diffused coronary artery disease with increased completeness of myocardial revascularization.</p>