Troponin as a marker of myocardial damage during coronary surgery with and without cardiopulmonary bypass.

BACKGROUND: The use of coronary surgery without cardiopulmonary bypass (CBP) has been growing during the last years. In order to compare myocardial damage during coronary surgery with and without CBP, perioperative Troponin T determinations were done. METHODS: Experimental design and setting: prospective, comparative. Cardiovascular surgery department. Patients, interventions and measures: 29 prospective patients who underwent elective coronary surgery were enrolled. Troponin T determinations (ng/ml) were done before surgical procedure, after a 2-hour and after a 12-hour postoperative. Population was divided in two groups: group 1, with CBP (17 patients); group 2, without CBP (12 patients). Variables in relation with population characteristics, myocardial damage and immediate postoperative haemodynamic results were all analyzed. RESULTS: Population characteristics and basal Troponin levels were similar for the two groups. Troponin T average levels at 2-hour postoperative period was 0.729 ng/ml and 0.067 ng/ml for group 1 and 2, respectively (p<0.00002). At 12 hours postoperative period Troponin T was 1.047 ng/ml and 0.183 ng/ml for group land 2 (p<0.0002). Haemodynamic performance was better in the group without CBP. CONCLUSIONS: Troponin T levels were significantly elevated in group 1, showing that surgical procedures without CBP caused less myocardial damage.

Reoperative coronary artery bypass without cardiopulmonary bypass.

BACKGROUND: Conventional reoperative coronary artery bypass grafting using cardiopulmonary bypass carries relatively high mortality and morbidity. METHODS: Seventy-seven patients underwent coronary artery bypass grafting without cardiopulmonary bypass in two centers between 1988 and 1994. Mean age was 65 +/- 8 years (mean +/- SD). Twenty-three (30%) were operated on urgently and 7 (9%) emergently. Nine (12%) were referred for operation up to 2 weeks after acute myocardial infarction. Fifteen patients (19%) had an ejection fraction less than or equal to 0.35. The mean number of grafts per patient was 1.7 (range, 1 to 3), and the internal mammary artery was used in 66 patients (86%). Only 18 patients (23%) received at least one graft to the circumflex artery. Hospital stay was 7.4 +/- 6.5 days. RESULTS: Early events included operative death in 4 patients (5.2%), nonfatal myocardial infarction in 3 (3.9%), sternal infection in 2 (2.6%), and stroke in 0 (0%). Follow-up (30 +/- 15 months) showed 11 deaths (5 cardiac, 6 noncardiac), 2 (2.8%) nonfatal myocardial infarctions, and return of angina in 9 patients (12.8%). One- and 4-year actuarial survival rates were 90% and 69%, respectively. CONCLUSIONS: Reoperative coronary artery bypass grafting without cardiopulmonary bypass has acceptable early and midterm outcome, and should be considered a viable alternative for properly selected patients.

Mitral valve replacement under video assistance through a minithoracotomy.

Minimally invasive techniques for mitral valve replacement offer an alternative for selected patients. In this report we present a woman with recurrent mitral valve stenosis, after mitral valve repair 10 years ago, who underwent mitral valve replacement through a minithoracotomy using stereo video assistance in combination with direct vision.

Direct coronary surgery without cardiopulmonary bypass in acute myocardial infarction.

From 1978 to 1995, 1420 patients underwent direct coronary surgery without cardiopulmonary bypass (CPB). Among them 32 consecutive patients (2.2%) were operated on from 1984 to 1995 for acute transmural myocardial infarction. There were 27 males and 5 females (mean age 59.2 +/- 6.7 years; range 35-72). Mean extent of coronary artery disease was 2.1 vessels/-patient. Four patients were admitted to surgery in cardiogenic shock, 5 with life-threatening ventricular arrhythmias. A mean time of 311 +/- 109 min (range 100-685 min) was recorded between the onset of symptoms and surgical reperfusion. Patients were operated on using saphenous vein or left internal mammary graft. Intraoperative transmural myocardial biopsies were taken in the area of myocardial infarction, 15 minutes before and 45 minutes after revascularization: biopsy specimens showed a marked reduction in signs of mitochondrial and myofibril damage. No in-hospital death occurred. Postoperative low cardiac output was never recorded. One patient had a mediastinitis. All patients, except one who died 8 years postoperatively, are alive at present: 1 is NYHA class II, 1 in NYHA IV and 27 are asymptomatic, with yearly treatmill test negative for recurrent myocardial ischemia. One patient underwent redo surgery 7 years after surgery for recurrent angina. First 5 consecutive patients were studied angiographically 1 to 30 days after surgery: all grafts were detected patent. In conclusion coronary surgery without CPB may be considered an alternative to conventional surgical revascularization of myocardial infarction.

Video assisted coronary bypass surgery.

An alternative way to revascularize coronary vessels is described, using arterial conduits without extracorporeal circulation. The heart is exposed via a small thoracotomy over the fifth left intercostal space. A thoracoscope is introduced into the thorax, to assist in the harvesting of the left internal mammary artery (LIMA). In selected patients with two or three vessel disease, the same procedure can be achieved on the right side, harvesting the right internal mammary artery to revascularize the right coronary artery. The gastroepiploic artery can be easily reached and used to revascularize the posterior descending artery, through a mini-subxiphoid median laparotomy. This technique was used to revascularize 30 patients from April 1994 to June 1995. All received a LIMA graft to the left anterior descending artery, and two had a free radial artery graft from the LIMA, sequentially bypassing the diagonal and obtuse marginal branches. There was neither perioperative mortality nor morbidity myocardial infarction. Fifteen patients were restudied angiographically before discharge. Average hospital stay was 43 +/- 11 hours.

Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. Experience in 2 cases.

A new surgical approach to mammary-coronary bypasses, to the left anterior descending artery, without the use of extracorporeal circulation, is described here. A minimal left anterior thoracotomy and the use of thoracoscopy are combined in this procedure performed in two patients (54-year-old male and 56-year-old male). Results were excellent: both patients were soon discharged from hospital (3 days patient 1 and 36 hours patient 2). Neither blood nor inotropic drugs were required. New angiographies previous to discharge were done, showing 100% patency of the mammary grafts. Both patients are angina-free. Due to its simplicity, and with more experience, this technique could be a good alternative for patients with severe lesions of the left anterior descending artery.

Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients.

Between May 1978 and March 1990, 700 patients were operated on with direct coronary surgery without extracorporeal circulation (ECC): 529 (76 percent) were male and 171 (24 percent) were female. The average age was 64 years (range, 35 to 86 years), 454 (65 percent) had unstable angina, 163 (23 percent) had stable angina, 51 (7 percent) had postmyocardial infarction angina, and 32 (5 percent) had acute myocardial infarction at the moment of the operation. In this series of patients, all branches of the coronary arteries were bypassed; the mammary artery was used in 40 percent of the cases, the average bypass per patient was 2.2 (range, 1 to 5), and 26 percent had associated disease of high risk to undergo ECC. The morbidity was 4 percent and the mortality for this series of patients was 1 percent; the probability of survival at seven years was 90 percent. This experience shows us that this surgery is an alternative in the treatment of coronary disease, especially for aged patients with associated disease, in some cases of acute transmural infarction, and also for patients who need coronary angioplasty. Also, it can improve the relation cost/benefit in coronary surgery.

A new surgical technique for fibrosed interventricular septum.

We describe a new surgical technique for the treatment of fibrosed interventricular septum, with or without left ventricular aneurysm. It is designed for patients whose ventriculograms revealed important septal dysfunction. Eleven patients ranging from 37 to 66 years of age were operated upon between 1984 and 1988. The left ventricle was opened through the aneurysm or the anterior wall when only anterior septal fibrosis was present. In patients with large aneurysms, two purse-string sutures were placed on the inside surface of the intact ventricle, around its limits, for approximation. The fibrosed septum was thus excluded from the new ventricular cavity. A patch was placed between the fibrosed and the healthy septum, reaching to the ventricular wall, all around the transitional edge. Both, ventricular geometry and function were improved. All patients were asymptomatic after one year follow-up.

Anastomosis mamariocoronaria sin circulación extracorpórea / Mammary-coronary anastomosis without extracorporeal circulation

Descripción de la anastomosis de la arteria mamaria como sustituto de la vena sin la utilización de la circulación extracorpórea en cirugía coronaria directa

Anastomosis mamariocoronaria sin circulación extracorpórea / Mammary-coronary anastomosis without extracorporeal circulation

Descripción de la anastomosis de la arteria mamaria como sustituto de la vena sin la utilización de la circulación extracorpórea en cirugía coronaria directa (AU)

Direct coronary surgery with saphenous vein bypass without either cardiopulmonary bypass or cardiac arrest.

From October, 1980 to April, 1983, 30 patients underwent direct coronary surgery without either cardiopulmonary bypass or cardiac arrest. Patients were selected according to the site of the lesion or the condition of the vessel, i.e. generally arteries with a good calibre (more than 1.5 mm), without big plaques in the anastomotic area and lesions limited to the left anterior descending, the diagonal or the right coronary arteries, independently from the clinical condition or state of left ventricular function. Eighteen had stable angina, 10 unstable angina, 2 post-myocardial infarction angina, and 4 had a severe concomitant disease. The operations performed were: 17 simple aorto-coronary bypasses, 11 double bypasses and 2 triple bypasses. When it was necessary to revascularize the diagonal or the left anterior descending artery, the operating table was rotated to the right, a gauze pack was applied posteriorly and the arteries were sutured with 6-0 or 7-0 prolene sutures. There were no deaths and no perioperative infarctions. It should be noted that to date this technique could be used only on 7% of our patients, but we consider this percentage could be increased in the future.

Atherosclerotic aneurysm of the subclavian artery.

Aneurysm of the subclavian artery is unusual and may have several causes. Cases of atherosclerotic origin have been very uncommon, specially if the aneurysm involves normal subclavian arteries. The authors report a case with these characteristics: a 62-year-old female had noted a tumor in the right supraclavicular fossa for thirty years. Angiographically, it proved to be an aneurysm. She was operated on, and a Dacron tubular prosthesis of 6 mm was implanted. The anatomo-pathologic study of the aneurysm showed typical atherosclerotic changes.