[Coronary surgery in elderly patients. In-hospital and long-term results]. / Cirugía coronaria en pacientes ancianos. Resultados hospitalarios y a largo plazo.

BACKGROUND: Taking into account the steady increase in the number of elderly patients requiring coronary artery bypass grafting, we sought to analyze the in-hospital and long-term evolution of a group of elderly patients (>/= 75 years) who underwent coronary artery bypass grafting, and to identify clinical predictors of mortality and long-term symptoms. METHODS: Between April 1996 and February 2000, 207 patients older than 75 years of age who had undergone coronary bypass grafting were prospectively and consecutively analyze. Mean age was 78.4 +/- 2.7. RESULTS: An average of 2.6 grafts/patients was constructed. Left mammary artery was used in 93% of patients. The in-hospital incidence of heart failure, atrial fibrillation, preoperative infarction and stroke was 38%, 29%, 4.8% and 2.8% respectively. The in-hospital mortality rate was 5.8%. Mean follow-up was 18 months (25th an 75th percentiles 9-29). Late mortality rate was 4.1% in eight patients. Excluding the in-hospital deaths, the estimated probability of survival (Kaplan-Meier) at 3 years was 94% and the survival freedom from symptoms was 86%. A multivariate analysis showed that only age was predictor of in-hospital mortality (OR 1.16, p = 0.009). Only peripheral vascular disease was found as a predictor of symptoms during the long-term follow-up (p = 0.001). CONCLUSIONS: In this series of senile patients who underwent coronary surgery, those of an older age (> 80 years) showed a higher risk of in-hospital mortality. The presence of peripheral vascular disease is useful in the prognosis assessment of the group.

Radial artery graft vasospasm.

We report an unusual case of vasospasm of a grafted radial artery complicated with ventricular fibrillation during the postoperative course of coronary artery bypass graft surgery. To our knowledge this is the first documented case of a radial artery graft spasm leading to a severe arrhythmia. The arrhythmia resolved spontaneously. Radial artery graft spasm was demonstrated by angiography and was successfully resolved by intravenous nitroglycerin administration.

Myocardial revascularization with radial and mammary arteries: initial and mid-term results.

BACKGROUND: The radial artery is being used with increasing frequency instead of the saphenous vein in coronary artery bypass grafts. We analyzed the in-hospital and midterm results in patients undergoing coronary artery bypass surgery in whom a combination of arterial grafts was used, including radial artery and one or both internal mammary arteries. METHODS: Between 1995 and 1998, 1,023 patients underwent coronary artery bypass surgery using arterial conduits. The left internal mammary artery and the right internal mammary artery were employed in combination with the radial artery. RESULTS: An average of 3.2 grafts per patient were done. The left internal mammary artery and radial artery were used in 100% of patients, the right internal mammary artery in 21.7%, and a venous graft in 31%. The operative mortality rate was 2.5%. On repeat angiography performed in 62 patients before their discharge, the arterial conduits were patent in 98.4%. Mean follow-up was 25.0 +/- 9.6 months (1 to 48 months). The probability of survival was 92.8%. CONCLUSIONS: Revascularization using mammary and radial artery grafts is safe. Complications are not higher than those observed with saphenous vein grafting. It was possible to use arterial conduits in all the patients, even in those with impaired left ventricular function.

Azygos vein diverticulum.

A 47-year-old woman, diagnosed with a diverticulum of the arch of the azygos vein, underwent surgical treatment. With nonspecific symptomatology, she presented one of the most uncommon anomalies of the large veins.

[Coronary revascularization surgery with arterial conduits. The technic, results and 4-year follow-up in 1023 consecutive patients]. / Cirugía de revascularización coronaria con conductos arteriales. Técnica, resultados y seguimiento a cuatro años en 1,023 pacientes consecutivos.

OBJECTIVE: The main objective of the present study was to analyze the in-hospital and mid term results obtained in 1,023 consecutive patients undergoing coronary artery bypass surgery (CABG) in whom a combination of arterial grafts was used: radial arteries (RA) and one or both internal mammary arteries (IMA). METHODS: From May 1995 to May 1998, 1,023 consecutive patients underwent CABG alone, using arterial conduits (AC) (one or two IMA and RA) for myocardial revascularization. The left internal mammary artery (LIMA) was employed as an "in situ" graft, and the right internal mammary artery (RIMA) as a free graft or "in situ" both in combination with the RA. The latter was connected to the LIMA through a T or Y anastomosis, or emerged directly from the ascending portion of the aorta. RESULTS: An average of 3.2 bypasses per patient were performed. The LIMA was used in 100% of the patients. The RIMA was used in 21.7% and the RA in 100% of the cases. Operative mortality was 2.5% (26 patients) and 32 (3.1%) suffered perioperative acute myocardial infarction. The first 62 patients were angiographically re-studied before discharge, and a 98.4% patency of the AC used was found. Mean follow up time was 25.0 +/- 9.6 months (range, 1 to 48 months). CONCLUSIONS: a) myocardial revascularization procedures using a combination of mammary and RA grafts are safe; b) in-hospital and mid term morbidity and mortality are not higher than those observed with saphenous vein grafts; c) it is possible to achieve complete myocardial revascularization with only AC, even in patients with impaired left ventricular function, and d) AC can be used in elderly patients.

Left ventricular myxoma.

A rare development of acute inferior myocardial infarction is reported in a 23-year-old man with no previous history of cardiovascular disease. In an echocardiographic study a left intraventricular tumour was diagnosed. Cineangiographic study showed normal coronary arteries. The tumour, a myxoma, originating in the ventricular septum, was resected through the left atrium after the anterior leaflet of the mitral valve was detached. Postoperative course was uneventful and the patient remained healthy 48 months after surgery.

Total myocardial revascularization with arterial conduits: radial artery combined with internal thoracic arteries.

OBJECTIVE: We prospectively tested the feasibility of achieving total arterial revascularization with the use of the radial artery to revascularize the circumflex, diagonal, and right coronary arteries combined with a left internal thoracic artery graft to the left anterior descending artery and, in some cases, a right internal thoracic artery graft to the right coronary artery. METHODS: In 164 patients, the radial artery was used as a free Y or T graft from the left internal thoracic artery. Of 568 grafts (3.5 +/- 1 [standard deviation] per patient), 296 (1.8 +/- 0.8 per patient) were constructed with the radial artery as single grafts or as double, triple, or quadruple sequential anastomoses to the circumflex, diagonal, and posterior descending arteries. Diltiazem was administered to prevent spasm. Forty-six patients underwent coronary angiography before discharge from the hospital. Follow-up time was 1 to 19 (9.5 +/- 6.1) months. RESULTS: Total arterial revascularization was achieved in 137 patients (83.5%). Three (1.8%) died postoperatively of sepsis, ventricular fibrillation, and heart failure, respectively. Three (1.8%) had postoperative myocardial infarction. No hand ischemia occurred. Angiography showed patency of all arterial conduits. Radial artery spasm appeared in 3 (6.5%) of 46 angiograms. Two patients (1.2%) died during the follow-up period of pneumonia and gastrointestinal tract bleeding, respectively. No other events or reoperations occurred, and 95.1% of the patients are free of symptoms. CONCLUSIONS: The radial artery, as a free Y or T graft from the left internal thoracic artery to the circumflex, diagonal, and right coronary arteries, permits total arterial revascularization with excellent patency rates, minimal morbidity and mortality, and no need for reoperation. Longer follow-up times are necessary to draw definitive conclusions.