Screening of carotid artery stenosis in coronary artery bypass grafting patients

We sought to evaluate the routine echo-Doppler screening of carotid artery stenosis in patients undergoing coronary artery bypass grafting. A total of 2179 consecutive patients who underwent coronary artery bypass grafting alone or with other cardiac surgery at Tehran Heart center, Tehran-Iran, between January 2005 and January 2006 were included in this retrospective study. Carotid Doppler was performed for 1604 [81.48%] of these patients. The patients' age ranged between 20 and 84 years [mean: 58.33, SD: 10.08 years]. Of the 1604 patients studied, 1186 [73.9%] were men, 592 [36.9%] had diabetes, 598 [37.3%] were smokers, and 194 [12.1%] cases had significant left main stenosis. Twenty-one [1.3%] patients had significant carotid stenosis [> 60% stenosis], which constituted 0.9% of all the bypass surgery candidates. Post-operative cerebrovascular accident was not detected in any of the patients with significant carotid stenosis, but cerebrovascular accident occurred in 22 [1.4%] of the patients without carotid stenosis. Magnetic resonance angiography [MRA] was conducted in 15 patients. In our univariate analysis, female gender [p value = 0.023], hypertension [p value 0.055], peripheral vascular disease [p value < 0.001], and age [p value = 0.001] were significant in the development of carotid stenosis. Pre-operative duplex carotid screening seems to be necessary in patients when there is hypertension, peripheral vascular disease, .female gender, and advanced age

Type B aortic dissection: management updates

Acute aortic dissection [AAD] is the most frequent catastrophic event of the aorta; it occurs nearly three times as frequently as the rupture of abdominal aortic aneurysm. Sixty percent of dissection cases are classified as proximal or type A and 40% as distal or type B, according to the Stanford Classification. The most frequent causes of death in acute type B dissection are aortic rupture and malperfusion syndrome. We herein review recent data suggesting different management modalities of type B aortic dissection, including medical, surgical, and endovascular treatments. Although medical therapy is still the standard approach in uncomplicated cases, there are subgroups of patients who may benefit from endovascular management. Endovascular techniques or surgery are valuable options for complicated cases. Hybrid suites, multidisciplinary approaches, and good imaging techniques can be considered as the key to success in this regard

Determinant factors of renal failure after coronary artery bypass grafting with on-pump technique

The aim of the present study was to investigate the determinant factors of acute renal failure [ARF] after isolated on-pump coronary artery bypass grafting [CABG]. This was a retrospective study of 13, 315 adult patients who underwent isolated CABG with cardiopulmonary bypass [CPB] in Tehran Heart Center from May 2002 to May 2007. The exclusion criteria were age <18, concomitant cardiac and/or noncardiac surgical operations, history of renal failure before surgery, and chronic renal failure requiring dialysis. Preoperative and operative variables were measured, and a multivariate logistic regression model was constructed to identify the independent risk factors for developing renal failure after on-pump CABG. Of the 13,315 patients, 3,347 [25.4%] and 90,883 [74.6%] were females and males, respectively, with a mean age of 58.63 +/- 9.48 years. ARF was detected in 85 [0.6%] of the patients with isolated on-pump CABG. The mean age of the patients was 58.63 +/- 9.48 years, and 25.5% of them were female. The multivariate logistic regression analysis identified age [OR = 1.035; p = 0.002], female gender [OR = 1.622; p = 0.037], history of peripheral vascular disease [PVD] [OR = 2.579; p = 0.042], diabetes mellitus [OR = 1.918; p < 0.001], emergent and urgent surgery [OR = 1.744 and OR = 7.901, respectively; p = 0.003], CPB time >70 min [OR = 1.944; p = 0.007], and intra-aortic balloon pump [IABP] insertion [OR = 10.181; p < 0.001] as the independent risk factors for ARF. The data showed that age, female gender, positive history of diabetes and PVD, urgent and emergent surgery, CPB time >70 min, and need for IABP were the independent determinant factors of ARF after on-pump CABG

Impact of diabetes mellitus on peripheral vascular disease concomitant with coronary artery disease

The aim of this study was to evaluate the impact of diabetes mellitus [DM] on peripheral vascular disease [PVD] in patients with coronary artery disease [CAD]. A total of 13702 consecutive patients who underwent coronary artery bypass grafting [CABG] at Tehran Heart Center between January 2002 and March 2007 were included in this study. The demographic data, PVD, and outcome of these patients were reviewed. CABG patients before surgery were detected for PVD [stenosis >/= 70% in the abdominal aorta; renal, carotid, and iliac arteries; or any other peripheral vascular system] with physical examination and past medical history. The suspected cases of PVD were, thereafter, confirmed via Doppler sonography or invasive angiography. This study recruited 4344 diabetic patients [mean age 59.30 +/- 8.7 years] and 9358 non-diabetic patients [mean age 58.42 +/- 9.9 years]. The diabetics were significantly older and had a higher incidence of PVD [2.7% vs. 1.8%], female gender, hypertension, renal failure, smoking, and dyslipidemia than the non-diabetics [P < 0.05]. There was no significant difference between the two groups with regard to family history and left main disease. Also, the mean ejection fraction [EF] was 48.85% +/- 10.4 and 49.35% +/- 10. In the patients with and without DM, respectively; and the difference was significant [P = 0.008]. The in-hospital mortality rate [mortality over a 30-day post-operative period] was 1.8% in the diabetics and 0.7% in the non-diabetics [P < 0.001]. In the multivariate analysis, PVD, left main disease, age, female gender, and EF were significant in the development of mortality amongst the diabetic patients with a respective odds ratio of 4.17, 5.54, 1.03, 2.86, and 0.95 [P

Prosthetic valve endocarditis: early outcome following medical or surgical treatment

Prosthetic valve endocarditis [PVE] is an important cause of morbidity and mortality associated with heart valve replacement surgery. The aim of the present study was to describe the early outcome of treatment in patients with PVE in a single center. The data of all the episodes of PVE registered at our institution between 2002 and 2007 were collected and analyzed retrospectively. The patients were assessed using clinical criteria defined by Durack and colleagues [Duke criteria]. The analysis included a detailed study of hospital records. The continuous variables were expressed as mean +/- standard deviation, and the discrete variables were presented as percentages. Thirteen patients with PVE were diagnosed and treated at our center during the study period. In all the cases, mechanical prostheses were utilized. The patients' mean age was 46.9 +/- 12.8 years. Women made up 53.8% of all the cases. Early PVE was detected in 6 [46.2%] patients, and late PVE occurred in 7 [53.8%]. Eleven [84.6%] patients were treated with intravenous antimicrobial therapy, and the other two [15.4%] required surgical removal and replacement of the infected prosthesis in addition to antibiotic therapy. Blood cultures became positive in 46.2% of the patients. Mortality rate was 15.4% [2 patients]. It seems that in selected cases with PVE, i.e. in those who remain clinically stable and respond well to antimicrobial therapy, a cure could be achieved by antimicrobial treatment alone with acceptable morbidity and mortality risk

Coronary artery bypass surgery versus medical treatment in patients with low ejection fraction and coronary artery disease

We compared the outcomes in patients with a low ejection fraction [EF] and multivessel coronary artery disease [CAD] who either underwent coronary artery bypass grafting [CABG] or received medical treatment [MT] after a viability study via dobutamine stress echocardiography [DSE]. We considered patients with CAD and left ventricular ejection fraction [LVEF] 25% [100% vs. 40%, p < 0.05]. The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium

Effect of cardiac rehabilitation program on heart rate recovery after percutaneous coronary intervention and coronary artery bypass grafting

The objective of this study was to evaluate the effect of a hospital-based cardiac rehabilitation program on heart rate recovery [HRR] in patients who received percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]. Two hundred forty patients, who completed 24 sessions of a cardiac rehabilitation program [phase 2] after PCI [n=62] or CABG [n=178] at the rehabilitation department of Tehran Heart Center were included in the present study. Demographic and clinical characteristics and exercise capacity at baseline and at follow-up were compared between the two groups. The main outcome measurements were: Resting heart rate, peak heart rate, and HRR. All the patients showed significant improvements in heart rate parameters from the baseline to the last sessions. The profile of atherosclerotic risk factors [except for diabetes mellitus] was similar between the PCI and CABG subjects. After eight weeks of cardiac rehabilitation, HRR increased averagely about 17 and 21 bpm among the CABG and PCI patients, respectively [p=0.019]. The results of the present study were indicative of an increase in HRR over 1 minute in patients irrespective of their initial revascularization modality [i.e. PCI or CABG] after the completion of cardiac rehabilitation. Be that as it may, the PCI patients achieved greater improvement in HRR by comparison with the CABG patients

Early outcome of coronary artery bypass grafting in patients less than 40 years old comparing with eldery patients

Age is one of the most important factors that have consistently emerged as the most potent predictors of mortality and morbidity after coronary artery bypass graft [CABG] surgery. However, early results of CABG in young patients in comparison with elderly ones have been different in previous surveys. The aim of this study was to compare shortterm mortality and morbidity in young versus older patients and evaluate the presence of risk factors and their influence on outcome in both groups. We conducted a retrospective database review of 13222 patients divided into two age groups: patients less than 40 years old [411 patients] and those older [12811 patients], who underwent CABG at Tehran Heart Center between January 2002 and January 2007. We also compared preoperative, operative, and postoperative characteristics between them and assessed the influence of the variables on the length of stay in hospital [LOS] in the two groups. Among postoperative complications, only atrial fibrillation [P<0.001] was more prevalent in the elderly group and other complications were similar. The thirty-day mortality rate was higher in the elderly group [1.1% vs. 0%, P=0.023]. Also, prolonged LOS [P<0.001] and ICU stay [P<0.001] were found more prevalent in the elderly group. Among the preoperative and postoperative variables, emergency surgery, diabetes mellitus, and previous myocardial infarction influenced the prolonged LOS in the young patients. Early mortality rate and prolonged length of stay in ICU and hospital were higher in the elderly than those in the young patients; however, other postoperative early complications were similar between the two groups

Early outcome of coronary artery bypass grafting in patients with severe left ventricular dysfunction

Left ventricular dysfunction is one of the most powerful predictors of early and late outcomes in patients who undergo coronary artery bypass grafting [CABG]. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay [LOS] after CABG in patients with an ejection fraction [EF] of 30% or less. Seven hundred seven patients who underwent CABG with EF 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. The thirty-day mortality rate [2.3% vs. 0.8%, P<0.0001], the mean of LOS [P<0.0001], and the mean of the length of ICU stay [P<0.0001] were higher in the severe left ventricular dysfunction group than in the control group. In patients with severe left ventricular dysfunction, the mean of NYHA score [P=0.0081], prolonged ventilation [P=0.0051], and renal failure [P=0.0606] were related to the 30-day mortality rate. Also, the prolonged LOS in these patients was correlated with the female gender [P=0.0018] and atrial fibrillation [P=0.0164]. Although left ventricular dysfunction is itself an important strong risk factor in patients undergoing CABG, the early outcome of CABG in patients with left ventricular dysfunction is acceptable and the management of this factor will help to reduce the mortality and total length of stay in hospital

Bifurcating Radial Artery: a Useful Anatomic Variation for Coronary Artery Bypass Grafting

A 56-year-old man with a two year history of chronic stable angina underwent elective coronary artery bypass grafting [CABG] due to angiographic report of three vessel disease and tight stenosis at proximal part of left anterior descending artery [LAD]. While harvesting of radial artery [RA], the distal half of radial artery was found to bifurcate to two parallel branches with equal size. We used this as a single conduit to bypass the first and second obtuse marginal [OM] branches. The patient had a smooth post-operative course and uneventful recovery

Impact of Dialysis on Open Cardiac Surgery

Dialysis patients frequently have coronary artery disease but are regarded as high risk patients for coronary artery bypass grafting [CABG]. Between February 2002 and September 2006, seventeen dialysis-dependent patients underwent isolated CABG at our center. CABG was performed under cardiopulmonary bypass [CPB] for all the patients. All cases had been maintained on hemodialysis and the duration of preoperative hemodialysis ranged from 6 to 24 months [mean 13.4 +/- 6.4]. The patients' characteristics, clinical and operative data as well as preoperative and mid-term outcome were reviewed. All patients were men with a mean age of 53 +/- 8.4 years. Mean preoperative ejection fraction was 45.5% +/- 10.4% [range 25 to 60%]. One internal mammary graft was used in 16 [94.1%] patients. Cardiopulmonary bypass and aortic cross-clamp times were 71.3 +/- 18.7 and 40.5 +/- 8.3 minutes respectively. The more frequent complication was prolonged mechanical ventilation in 2 [11.7%], there was no preoperative mortality. In mid-term follow-up [mean time: 11.8 +/- 9.5 months] the mid-term mortality rate was 20% [3 patients]. CABG in chronic renal dialysis patients can be accomplished with acceptable short and mid-term morbidity and mortality