Subject(s)
Angina Pectoris/surgery , Coronary Artery Bypass , Angina Pectoris/mortality , Follow-Up Studies , Graft Occlusion, Vascular , Humans , Outcome Assessment, Health Care , Randomized Controlled Trials as Topic , Survival Analysis , United States , United States Department of Veterans AffairsSubject(s)
Angina Pectoris/surgery , Coronary Artery Bypass , Postoperative Complications/mortality , Angina Pectoris/mortality , Follow-Up Studies , Humans , Multicenter Studies as Topic , Randomized Controlled Trials as Topic , Survival Rate , Treatment Outcome , United States , United States Department of Veterans AffairsSubject(s)
Coronary Artery Bypass , Minimally Invasive Surgical Procedures , Coronary Artery Bypass/economics , Coronary Artery Bypass/standards , Cost Control , Evaluation Studies as Topic , Humans , Minimally Invasive Surgical Procedures/economics , Minimally Invasive Surgical Procedures/standardsABSTRACT
Bloodless cannulation of the aorta can be accomplished easily. A full thickness stab wound prior to insertion of the cannula is unnecessary as the aorta's inner layers have little strength.
Subject(s)
Aorta , Catheterization/methods , Cardiopulmonary Bypass , Humans , Suture TechniquesABSTRACT
Randomised trials that compare new procedures with established ones must avoid prerandomisation bias and must allocate patients to treatment groups based on objective or quantitative criteria, not on subjective clinical judgment. Risk, length of follow up, and sample size must be used to calculate the statistical power of the study, so that a significant difference between treatments does not remain undetected (a type II error). There should already be sufficient experience with the new procedure so that complication rates have stabilised, and participating operators are equally comfortable with all procedures being studied. Even with the above stipulations, randomised trials that compare medical with procedural treatment pose additional problems (many of which have been omitted from this necessarily brief discussion); few such studies have had a major impact on clinical practice. The most useful randomised studies of procedures are those that compare one procedure with another, or those that assess a specific refinement in an established procedure, such as the use of different anticoagulation regimens for coronary stents. Fortunately, clinically useful information has always been available from non-randomised studies. The recent trend towards meta-analysis of large clinical series can substitute for those randomised studies that are unlikely to be helpful.
Subject(s)
Randomized Controlled Trials as Topic , Surgical Procedures, Operative , Drug Therapy , Humans , Patient Selection , Treatment OutcomeABSTRACT
A technique is described for using the internal mammary artery to bypass the left anterior descending coronary artery and another adjacent coronary artery even when the alignment of the two vessels is not favorable for a conventional sequential graft. The distal end of the mammary artery is amputated and used to construct a Y graft to the anterior descending artery and to the secondary target vessel.
Subject(s)
Internal Mammary-Coronary Artery Anastomosis/methods , Coronary Vessels/surgery , Humans , Mammary Arteries/surgeryABSTRACT
Atrial fibrillation is found at late follow-up in approximately half of all adults who have had correction of atrial septal defect, even if it was not present preoperatively. These patients are thus exposed to the risks of stroke and chronic drug therapy even after a successful operation. Simultaneous surgical correction of atrial septal defect and atrial fibrillation was accomplished in a 52-year-old man by means of the Cox/maze procedure. The small added risk and the substantial benefit of eliminating atrial fibrillation suggest that this approach is warranted in selected adults with atrial septal defect.
Subject(s)
Atrial Fibrillation/surgery , Heart Septal Defects, Atrial/surgery , Atrial Fibrillation/complications , Heart Septal Defects, Atrial/complications , Humans , Male , Methods , Middle AgedABSTRACT
Coronary artery bypass without cardioplegia remains the preferred technique at many centers around the world. This report describes in detail a technique that emphasizes intermittent cross-clamping of the aorta at mild hypothermia (30 degrees C). Since coronary bypass procedures require brief interruptions of coronary blood flow only for the distal anastomoses, the duration of myocardial ischemia with this technique is not prolonged by unexpected changes in the operative plan. Many bypass grafts can also be carried out without cross-clamping of the aorta by using local control of the coronary arteries. The increasing number of elderly patients with atherosclerotic aortas that cannot be safely clamped makes it helpful for all cardiac surgeons to be familiar with noncardioplegic techniques.
Subject(s)
Coronary Artery Bypass/methods , Heart Arrest, Induced , Aorta/injuries , Aortic Diseases/surgery , Aortic Valve Insufficiency/surgery , Arteriosclerosis/surgery , Constriction , Coronary Artery Bypass/instrumentation , Heart Valve Prosthesis , Humans , Hypothermia, Induced , Intraoperative Complications , ReoperationABSTRACT
Left ventricular venting has many physiologic and practical benefits. A venting technique is described that employs a simple, closed system which allows the perfusionist to monitor left ventricular distention. By monitoring the left ventricular volume the perfusionist can regulate the degree of negative pressure on the vent and thus reduce the chance of air entering the heart.
Subject(s)
Coronary Artery Bypass/methods , Heart Ventricles/surgery , Humans , MethodsABSTRACT
Although some surgeons still prefer noncardioplegic coronary bypass, most surgeons are skeptical of its suitability for high-risk patients. We analyzed the first 3000 patients who had primary coronary bypass without cardioplegia since our program's inception. Patients with reoperations, valve operations, or carotid endarterectomies were excluded. Multivariate predictors of operative death included age, sex, left ventricular dysfunction, preoperative intraaortic balloon pumping, and urgency of operation. Eight hundred seventy-nine patients (29%) were more than 70 years of age; 795 (27%) were female; 290 (9.7%) had an ejection fraction less than 0.30, and another 77 (2.6%) had left ventricular aneurysms; 196 (6.5%) had an acute myocardial infarction, and another 397 (13%) had a myocardial infarction less than 1 week preoperatively; 917 (31%) had rest pain in the hospital (preinfarction angina). Only 790 (26%) had elective operations. The overall operative mortality rate was 1.47% (44/3000): The mortality rate for elective operations was 0.5% (4/790); urgent 1.7% (28/1687); emergency 2.3% (12/523). In patients with an ejection fraction less than 0.30 the mortality rate was 6.2% (18/290); with age more than 70 years, it was 3.9% (34 of 879); with acute myocardial infarction it was 3.1% (6/196); and with left ventricular aneurysmectomy it was 1.3% (1/77). Inotropic support after leaving the operating room was needed in 6.6% (199 patients), and 1% (30 patients) required new intraaortic balloon pumping postoperatively (two of these 30 patients died). These results provide reassurance that noncardioplegic coronary artery bypass grafting provides excellent myocardial protection and operating conditions for primary coronary bypass and is particularly suitable for high-risk patients.