[Coronary surgery after 70 years of age]. / Cirurgia coronária depois dos 70 anos.

Previous reports on coronary artery bypass grafting in elderly patients have not usually addressed the current era of aggressive percutaneous angioplasty. To investigate this important subgroup of patients, we analyzed our recent coronary artery bypass grafting experience with patients 70 years of age or older from May 1988 to August 1993, 158 consecutive patients in this age range (mean age 70.3 years) underwent surgical revascularization at our institution. Overall operative mortality was 4.4% (7/158), with 71.4% (5/7) of deaths due to cardiac causes. Postoperative morbidity occurred in 50.6% (80/158) of patients but was of a serious nature in only 12.0% (19/158). Surgical priority was significantly correlated with operative mortality: 1.6% (2/122) for elective cases and 17.2% (5/29) for urgent or emergency cases (p < 0.01). Univariate analysis isolated the need for postoperative inotropic support or mechanical assistance, perioperative myocardial infarction and reoperation for bleeding as significant risk factors for operative mortality (p < 0.01). Of the patients discharged from the hospital, 144 (95.4%) were followed up for a mean of 23 months (3-62). During the follow-up period there were 3 deaths, all from non cardiac causes, and 92.3% of the patients were in Canadian Cardiovascular Society class I (CCS). These results indicate that, although with somewhat higher morbidity and mortality rates, elderly patients have a very acceptable operative risk in the current era of high-risk coronary artery bypass grafting, particularly if elective revascularization is possible.

Advances in surgical treatment of acquired valve disease.

After the first two decades of constant improvements in valve prostheses, no major advance has occurred since the mid 1980s. Hence, valve replacement remained the exchange of one disease for another. With minor and, for the most part, statistically nonsignificant variations, the spectrum of late valve-related complications remained unaltered and the few series published in the year under review brought no additional information of relevance. By contrast, in the past few years there has been a growing enthusiasm for the use of allografts, stentless porcine bioprostheses, and pulmonary autografts. Not only was there a surge of interest in the allografts as aortic valve substitutes, but in the past year there have also been several reports of use for whole or partial mitral or tricuspid valve replacement. On the other hand, stentless bioprostheses are also gaining increasing acceptance, and all major manufacturers of heart valve prostheses have models for use in different situations and with different techniques. Finally, the Ross operation is now being performed around the world. Despite these advances, valve repair still merits the preference of many surgeons. Mitral valvuloplasty preserves left ventricular function much better than valve replacement. By contrast, the results of aortic valve repair look much less impressive. Lastly, this work focuses on recent reports on special aspects of surgery for native or prosthetic valve endocarditis, especially with the use of allografts or autografts; on the results of valve surgery in elderly patients, a fast growing group; and on the controversial issues of anticoagulation in patients with artificial valves.

[Revascularization of the left coronary system with both internal mammary arteries in disease of the left main artery]. / Revascularização do sistema coronário esquerdo com dupla artéria mamária interna na doença do tronco comum.

Although the longterm patency of the internal mammary artery (IMA) has been clearly demonstred, some doubts have been cast as to the perioperative adequacy of its flow. Hence, the sole use of these conduits in patients with left main disease (LMD) has been cautioned. To clarify the significance of this problem in our own population, we have considered in this study, 110 patients with significant LMD subjected to isolated myocardial revascularization from November 1992 trough November 1994. These patients were retrospectively divided into two Groups based on the type of revascularization of the left coronary territory: Group I-35 patients (mean age 51.8 +/- 6.0 years) in whom both the left anterior artery and branches of the circunflex artery were grafted with the left and right IMAs, respectively; and Group II-85 patients (mean age 63.9 +/- 7.7 years) in whom the anterior descending artery received the left IMA and the circunflex system received saphenous vein grafts. No patient in Group I received venous grafts in the left coronary system and in four patients of Group II the rigth IMA was anastomosed to the right coronary artery. The operative mortality was 0% in Group I and 3.5% in Group II (p = NS). The rate of perioperative myocardial infarction was 2.9% and 2.3%, respectively. The incidence of other complications was also similar in the two groups with regards to the need for inotropes (8.6% in the Group I and 7.0% in group II), and the prevalence of arrhythmias (22.8% and 23.5%) but was marginally higher in Group I with regards to reoperation for haemorrhage (8.6% and 3.5%) and sternal dehiscence (5.7% and 2.3%). The mean time of hospital admission was 8.3 days for both groups. The use of both IMAs as the sole conduits for revascularization of the left coronary system in patients with LMD did not increased surgical risk. Also, the hypothesis of insufficient blood flow to the myocardium does not appear to be supported by this study.

[Coronary surgery in patients 70 years and older]. / Cirurgia coronária depois dos 70 anos.

Previous reports on coronary artery bypass grafting in elderly patients have not usually addressed the current era of aggressive percutaneous angioplasty. To investigate this important subgroup of patients, we analyzed our recent coronary artery bypass grafting experience with patients 70 years of age or older-From May 1988 to August 1993, 158 consecutive patients in this age range (mean age 73.0 years) underwent surgical revascularization at our institution. Overall operative mortality was 4.4% (7/158), with 71.4% (5/7) of deaths due to cardiac causes. Postoperative morbidity occurred in 50.6% (80/158) of patients but was of a serious nature in only 12.0% (19/158). Surgical priority was significantly correlated with operative mortality: 1.6% (2/122) for elective cases and 17.2% (5/29) for urgent or emergency cases (p < 0.01). Univariate analysis isolated the need for postoperative inotropic support or mechanical assistance, perioperative myocardial infarction and reoperation for bleeding as significant risk factors for operative mortality (p < 0.01). Of the patients discharged from the hospital, 144 (95.4%) were followed up for a mean of 23 months (3-62). During the follow-up period there were 3 deaths, all from non cardiac causes, and 92.3% of the patients were in Canadian Cardiovascular Society class I (CCS). These results indicate that, although with somewhat higher morbidity and mortality rates, elderly patients have a very acceptable operative risk in the current era of high-risk coronary artery bypass grafting, particularly if elective revascularization is possible.

[Coronary revascularization with the double internal mammary artery]. / Revascularização coronária com dupla artéria mamária interna.

From January 1989 through December 1991, 730 patients (mean age 60.4 years) underwent coronary revascularization. In 124 patients (17%), with a mean age of 51.8 +/- 7.9 years, both internal mammary arteries (IMA) were used. Of these, 19 (15%) had diabetes mellitus and 11 (9%) were obese, and 72 (58%) had history of myocardial infarction. Fifty three (45%) patients were in class III and 17 (14%) were in class IV (Canadian Cardiovascular Society), and 27 (22%) had moderate to severe left ventricular dysfunction. Ten (8.1%) patients had left main stem coronary artery disease and 5 (4.0%) had a left ventricular aneurysm. The total number of distal anastomoses performed was 382 (3.1/patient). In 87 (70%) patients one or more saphenous vein grafts (1.2/patient) were used in addition to both mammary arteries. Hence, 279 distal anastomoses were constructed using arterial conduits (2.3/patient). In one patient the right gastroepiploic artery was also used. The venous grafts were predominantly (71%) constructed to the right coronary artery. The left IMA was used as a free graft in 3 (2.3%) patients and as a pedicled graft in the remainder patients, predominantly to the territory of the left anterior descending artery and its diagonal branches (92%). The right IMA was used as a free graft in 100 (81%) patients, mainly to the territory of the circumflex coronary artery and as a pedicled graft in 24 patients, in 21 to the territory of right coronary artery. Thirty nine (31%) patients required endarterectomy of the right coronary artery. Mean cardiopulmonary bypass time and mean duration of aortic cross-clamping were 78.6 minutes and 29.6 minutes, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)