Coronary artery bypass following percutaneous transluminal coronary angioplasty.

During a 4-year period, 286 patients underwent coronary artery bypass grafting (CABG) following percutaneous transluminal coronary angioplasty (PTCA). Seventy-three patients had single-vessel and 213 (74.5%) had multivessel coronary artery disease. Twenty-nine patients underwent PTCA because of an evolving acute myocardial infarction (MI). Forty-two patients had previously undergone 47 CABG procedures. One hundred fifteen patients underwent CABG on an emergency basis. Indications for emergency CABG after PTCA were prolonged chest pain (79.1%), worsening of coronary artery obstruction (59.1%), "current of injury" by electrocardiogram (31.3%), cardiogenic shock (27.8%), and, in a lesser incidence, ventricular fibrillation, coronary artery dissection (without obstruction), heart block, and intractable cardiac arrest. The 286 patients underwent 2.1 CABG procedures per patient with a thirty-day mortality of 6.3% (18 patients). The incidence of acute MI was 43.5 versus 4.1%; low cardiac output syndrome, 34.8 versus 7.0%; and operative death, 11.3 versus 2.9% in the emergency and nonemergency groups, respectively. Other significant predictors of operative death were previous CABG (16.7 versus 4.5%), multivessel coronary artery disease (8.0 versus 1.4%). Late follow-up reveals a mortality of 1.4% per year in those patients who were early survivors of CABG.

Right coronary spasm complicating electrode catheter ablation of a right lateral accessory pathway.

Severe focal right coronary artery spasm, demonstrated on angiography, occurred in a 12 year old girl undergoing attempted electrode catheter ablation of a right atrial-right ventricular free wall accessory pathway.

Incessant focal atrial tachycardia: a surgically remediable cause of cardiomyopathy.

Following electrophysiological study and intraoperative mapping, an 11-year-old girl with incessant automatic atrial tachycardia and clinical features of congestive cardiomyopathy underwent successful surgical excision of an ectopic focus localized to the right atrial appendage. Dramatic clinical improvement resulted, and echocardiographic indices of left ventricular function returned to normal over a 1 year follow-up period.

Coagulation abnormalities in patients undergoing myocardial revascularization.

One hundred patients were screened for hypercoagulability preoperatively and on the third, seventh, tenth, fourteenth, and twenty-first days postoperatively. Patients found to have hypercoagulability were treated with heparin, aspirin, and Coumadin. When the abnormality was present preoperatively, treatment was continued for the duration of the patient's life. Those patients in whom abnormalities developed postoperatively were given anticoagulants until cardiac catheterization 6 months following their operation. Twenty-four of the 100 patients had no coagulation abnormalities preoperatively or postoperatively. Fifteen patients were found to have abnormality prior to operation. Their predominant abnormality was low antithrombin III activity. Sixty-one patients became hypercoagulable postoperatively. Predominant abnormality in this group of patients was increased thrombin generation and increased platelet adhesiveness. Evaluation of patients in this study group revealed a decrease in the incidence of pulmonary embolism, an increase in the patency of vein grafts, and the elimination of anticoagulant therapy in 24 percent of the patients.

Coagulation factors influencing thrombosis of aorta-coronary bypass grafts.

Thirty patients in whom all aorta-coronary artery vein grafts became occluded within one year of operation, as demonstrated by cardiac catheterization, were evaluated for hypercoagulability. A total of 59 grafts were constructed in these patients. At operation, blood flows of 35 to 90 c.c. per minute were measured through the grafts. In 23 of the 30 patients, the blood was to be hypercoagulable, as evidenced by a low level of antithrombin III activity, high thrombin generation index, high factor VII values, or high platelet adhesivity. Another group of 11 patients (total number of grafts, 23) had all grafts patent at cardiac catheterization. These patients had flows through the grafts ranging from 20 to 125 c.c. per minute. None of the patients with patent grafts had hypercoagulable blood. The status of runoff was comparable between the patients with open grafts and those with occluded grafts.

Plasmacytoma arising in a pacemaker pocket.

A 48-year-old man developed a plasmacytoma in the subcutaneous pocket of a titanium covered pulse generator that had been inserted sixteen months previously. The tumor represented a cutaneous manifestation of myelomatosis. The presence of a pacemaker may affect the detection and treatment of tumors arising in the region of pulse generator pockets. Possible cause-and-effect relationships are explored.