LDL-apheresis: indications and clinical experience in a tertiary cardiac centre.

OBJECTIVE: To determine the efficacy and safety of liposorber D low-density lipoprotein (LDL) apheresis system in high-risk cardiac patients. DESIGN: Retrospective analysis of 466 treatments undertaken in eight patients with coronary heart disease. Five patients had severe heterozygous familial hypercholesterolaemia (FH), one had severe hypertriglyceridaemia and two were cardiac transplant recipients with FH intolerant to statins. Acute reductions during single sessions and preprocedural long-term changes in lipoprotein subfractions, laboratory safety parameters, adverse events and clinical outcome were recorded. RESULTS: In 352 treatments performed in seven patients, acute reductions averaged 52.8% (standard deviation: 8.61%) for total cholesterol (TC), 61.8% (10.13%) for LDL-cholesterol (LDL-C), 21.1% (9.66%) for high-density lipoprotein cholesterol (HDL-C), 71.1% (median) for lipoprotein (a) [Lp(a)] and 44.5% (14.42%) for triglycerides (p < 0.05). Long-term reductions of TC, LDL-C, Lp(a) and triglycerides by 18.1%, 21.7%, 9.4% (median) and 19.8%, respectively, were achieved. HDL-C was increased by 7.5%. Results from the patient with severe hypertriglyceridaemia were analysed separately because of markedly elevated TC and triglycerides. Technical and clinical complications were mild and showed an incidence of 16.65% and 12.45% respectively. The most common clinical event was transient hypotension (5.8%), whereas vascular access difficulties (11.3%) represented a common technical problem. All patients demonstrated clinical improvement. However, two patients treated via a central line developed septicaemia, resulting in endocarditis in one of them. CONCLUSION: Liposorber D is a simple, safe and effective modality in reducing atherogenic lipoproteins in dyslipidaemic high-risk cardiac patients. The treatment via an arteriovenous fistula is the preferred vascular access in this type of patient.

Quality of life and coping following minimally invasive direct coronary artery bypass (MIDCAB) surgery.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery has been shown to be a promising technique for surgical treatment of single or double vessel disease. However, little is known about quality of life, mood state or coping in this group of patients. The records of 55 consecutive patients who underwent MIDCAB surgery at Harefield Hospital between April 1999 and May 2001 were reviewed. In order to assess quality of life, mood state and coping, patients were contacted by telephone to conduct a semi-structured interview and were subsequently sent four questionnaires. The measures used were the Hospital Anxiety and Depression Scale, the Short Form Health Survey, the WHOQoL-BREF and the COPE. Forty-eight patients were contacted by telephone, forty-four of whom returned the completed questionnaires. Overall ratings of quality of life were excellent for the majority of patients, and rates of anxiety and depression were lower than previously found following coronary artery bypass surgery. It is concluded that following MIDCAB surgery quality of life and mood state outcomes are encouraging. However, a prospective, longitudinal study is now required to further elucidate the relationship between quality of life, mood state and coping and to identify predictive factors for physical and psychological outcome following this new surgical technique.

Epicardial haematoma: rare cause of acute myocardial ischaemia.

Pericardial effusion and coronary dissection are well known complications of percutaneous transluminal coronary angioplasty (PTCA). We report a rare case of sub-epicardial haematoma after PTCA, leading to local compression and cardiogenic shock. We discuss the successful management of this problem.

Multi-vessel off-pump coronary artery bypass grafting can be taught to trainee surgeons.

BACKGROUND: Although, Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively. METHODS: Registry data, notes and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training programme for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it has had an established recent experience in performing non-selective OPCAB for all coming-in patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses. RESULTS: The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed satisfactory seventeen (100%) distal anastomoses. CONCLUSION: With appropriate training, it is possible for trainees to learn OPCAB and perform multi-vessel revascularization in relatively high-risk patients with good results.

Difference in the mortality of the CABRI diabetic and nondiabetic populations and its relation to coronary artery disease and the revascularization mode.

In diabetics with coronary artery disease (CAD), there remains uncertainty as to whether revascularization by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass surgery (CABG) is preferable. To address this, 4-year mortality and level of pre- and postrevascularization angiographic CAD (measured by a series of coronary scores) were compared between both diabetics and nondiabetics and between revascularization modes in the Coronary Angioplasty versus Bypass Revascularization Investigation population as a whole, and then substratified by diabetic status and then by procedure to which they were randomized. The 1,054 randomized subjects contained 125 diabetics (11.9%) who had significantly greater mortality than nondiabetics (RR 2.19, p = 0.001). Among diabetics or nondiabetics, there was no significant mortality difference between those randomized to PTCA versus those to CABG. Diabetics randomized to PTCA and those to CABG had higher mortalities than respective nondiabetics; the association reached significance only in the former (RR 2.41, p = 0.002). All subgroups had similar prerevascularization CAD. Postrevascularization residual CAD was consistently significantly greater in PTCA than in respective CABG subgroups. Most measurements of CAD were greater in diabetic than in nondiabetic subgroups, but none was significant. In the Coronary Angioplasty versus Bypass Revascularization Investigation, diabetics had double the mortality of nondiabetics; this difference was statistically significant both for the entire population and for those randomized to PTCA, but not for those randomized to CABG. Among diabetics or nondiabetics, there was no significant mortality difference between PTCA and CABG. The higher diabetic mortality was more likely related to more rapid disease progression than to greater postrevascularization disease.

Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery?

BACKGROUND: Despite increasing data supporting its use, the uptake of radial artery coronary bypass grafting by most surgeons remains low. This may partly be from perceptions that it increases risk or complexity of coronary surgery. METHODS: Data on 151 patients who had radial grafts are compared with 179 concurrent nonrandomized controls that underwent conventional surgery using saphenous vein. Additionally, telephone interviews were conducted on 127 radial recipients to assess subjective outcome. RESULTS: Cardiopulmonary bypass and cross-clamp times were similar in both groups (72 versus 74 minutes and 20 versus 22 minutes). Morbidity was comparable (mortality 1% versus 2%; cerebral vascular accident 1% versus 2%; sternal infection 1% versus 2%; resternotomy 4% versus 6%). Of 127 patients contacted, 41 (32%) reported that they had experienced parasthesia, and 65 (51%) reported numbness related to radial harvest; of these, 75% reported their symptoms as resolved or resolving. Early angiography performed in 36 patients revealed a radial patency rate of 92%. CONCLUSIONS: Concerns about increased morbidity and mortality should not hinder adoption of radial artery grafting.

The effect of adjusting for baseline risk factors and post revascularisation coronary disease on comparisons between coronary angioplasty and bypass surgery.

BACKGROUND: In CABRI at 1 year PTCA was associated with greater repeat revascularisation and angina (but not myocardial infarction or death). We determined whether adjusting for baseline risk factors and post revascularisation coronary disease offsets this disadvantage of PTCA. METHODS: In the CABRI population the crude association of revascularisation mode (i.e. PTCA or CABG) with four clinical outcome (i.e. mortality, myocardial infarction, repeat revascularisation and angina) was adjusted for the baseline risk factors using a logistic regression model for each clinical outcome. A number of measures of angiographic coronary disease were used to assess post revascularisation coronary disease. One at a time, each of these measures was added to each of the four outcome models, to adjust for post revascularisation coronary disease. RESULTS: Comparing adjusted and crude unadjusted association of PTCA with repeat revascularisation there was an increase from 12.8 (P<0.0005) (crude relative risk) to 16.7 (P<0.0005) (adjusted odds ratio), with angina, from 1.89 (P=0.001) to 1.98 (P<0.0019), and with mortality from 1.84 (P=0.092) to 2.15 (P=0.060). PTCA was not significantly associated with myocardial infarction, either crudely or after adjustment. CONCLUSION: Adjusting for baseline risk factors and post revascularisation coronary disease tended to strengthen rather than weaken associations between PTCA and 1 year mortality, repeat revascularisation and angina at 1 year.

Influence of clinical and angiographic factors on development of collateral channels.

BACKGROUND: The degree of coronary collateralization is believed to be related to several clinical and angiographic factors. The duration and frequency of angina may be important factors in determining development of collateral channels. OBJECTIVE: To assess these factors for a consecutive series of patients suspected to have coronary artery disease. METHODS: Patients without at least one stenosis of < 50% and patients who had previously undergone bypass surgery were excluded from our study. Severity of stenosis was quantified by digital analysis, antegrade flow in terms of TIMI grade, and collaterals using the Rentrop classification. RESULTS: We reviewed 106 patients [mean age 61 years (range 35-84), 77.6% men]. Of these, 22 (21%) had presented with an acute coronary syndrome on this admission, whilst 46 patients (43%) had previously had an acute coronary syndrome. Collaterals were more likely in patients with stenoses of > 90% (Spearman correlation 0.65, P < 0.001) in patients with lower than normal TIMI flow grade (Spearman correlation 0.86, P < 0.01) and were related to regions of hypokinesis (Spearman correlation 0.35, P < 0.01). Significant collaterals were present in 14 patients (13%) despite their having TIMI grade II/III flow. Two of these patients had grade 2/3 collaterals with TIMI grade II/III antegrade flow. Degree of collateralization was not related to chronicity and frequency of symptoms, age, risk factors for atherosclerosis and nature of presentation (i.e. acute or stable symptoms). CONCLUSION: The likelihood of coronary collateralization cannot be prospectively predicted from clinical history alone, but appears to be largely a function of severity of stenosis and level of antegrade flow. A few patients develop high-grade collateral channels despite the presence of good antegrade flow.

Long-term results after aortic valve replacement in patients with congestive heart failure. Homografts vs prosthetic valves.

OBJECTIVES: The aim of this study was to assess the influence of valve substitute (homograft vs prosthetic valve) on the long-term survival and late valve-related complication rates following aortic valve replacement in patients with aortic valve disease and congestive heart failure. BACKGROUND: The effect of choice of valve substitute on outcome after aortic valve replacement in patients with pre-operative heart failure is unknown. The superior haemodynamic profile of homografts may be of particular benefit. METHODS: We retrospectively analysed pre-operative, operative and follow-up data on 518 adults in functional classes III and IV, who, over the 25 years 1969-1993, had their initial aortic valve replacement at Harefield hospital. Follow-up conducted during 1996 to April 1997 and totalling 4439 patient-years was 96.1% complete. Using multivariate analysis, independent risk factors for different complications and mortality were defined. RESULTS: Overall 5-, 10- and 20-year survival was 80+/-2%, 62+/-2% and 30+/-3%, respectively, with no significant difference between valve types. However, homografts (n=381) independently reduced the rate of serious complications and cardiac death, whereas mechanical valves were an independent adverse risk factor for late mortality. The rates of anticoagulant-related bleeding and thromboembolism were increased by mechanical valves, whereas primary tissue failure was the main complication of homografts. CONCLUSIONS: Long-term outcome of homograft aortic valve replacement in patients with congestive heart failure is acceptable, with a reduced rate of serious complications and cardiac death. Further improvements would be expected if the rate of primary tissue failure could be reduced.

Relation between coronary artery disease, baseline clinical variables, revascularization mode, and mortality. CABRI Participants. Coronary Angioplasty vs. Bypass Revascularisation Investigation.

The Coronary Angioplasty vs. Bypass Revascularisation Investigation (CABRI) trial comparing percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass grafting did not show a difference in mortality with either procedure. Nonrandomized studies suggest that coronary artery disease (CAD) severity and distribution influences outcome. In the present study we explored the effect of prerevascularization CAD on 1-year mortality in the CABRI population, while adjusting for other baseline variables. Of the 1,054 patients recruited, there were sufficient angiographic results to derive the CAD scores in 974 (92.4%). Of these 974, there were 32 deaths. A number of CAD scores, both weighted for proximal disease (Duke and Leaman) and nonweighted, were used. These scores were then cross-tabulated against mortality. Demographic and clinical variables were also cross-tabulated against mortality and used to derive an initial logistic regression model to predict mortality. The effect of adding each of the CAD scores to this initial model was then assessed. After inclusion of the CAD scores, the best model was: (1) presence of peripheral vascular disease (odds ratio [OR] 3.89, p = 0.0025), (2) previous cerebrovascular accident (OR 2.86, p = 0.043), (3) older age (OR 1.05, p = 0.039), (4) a higher Duke score (OR 2.84, p = 0.0061), and (5) having undergone PTCA (OR 2.12, p = 0.047). In the CABRI population, adjustment for baseline variables, including prerevascularization CAD, revealed significantly higher mortality in those who underwent PTCA than in those who underwent coronary artery bypass grafting.

Stabilisation of medically refractory ventricular arrhythmia by intra-aortic balloon counterpulsation.

OBJECTIVE: To review the efficacy of intra-aortic balloon counterpulsation (IABCP) in medically refractory ventricular arrhythmia. DESIGN: Retrospective analysis of the outcome of patients with ventricular arrhythmia treated with IABCP after transfer between 1992 and 1997. SETTING: Tertiary cardiac referral centre. PATIENTS: 21 patients (mean age 58 years) who underwent IABCP for control of ventricular arrhythmia. All had significant left ventricular impairment (mean ejection fraction 28.6%); 18 had coronary artery disease. RESULTS: Before IABCP, 10 patients had incessant monomorphic ventricular tachycardia and 11 had paroxysmal ventricular tachycardia and/or ventricular fibrillation (VT/VF). IABCP resulted in suppression of ventricular arrhythmia in 18 patients, of whom 13 were weaned from IABCP. After stabilisation of ventricular arrhythmia, 10 patients were maintained on medical treatment alone and one underwent endocardial resection. IABCP was maintained until cardiac transplantation in five patients. One patient had a fatal arrest before discharge and one died from progressive heart failure. IABCP failed to control ventricular arrhythmia in three patients and was subsequently discontinued. A cardiac assist device was employed in one of these until cardiac transplantation; the other two were eventually stabilised on medical treatment. Nineteen patients were discharged from hospital. Overall survival was 95% at mean follow up of 25.7 months. CONCLUSIONS: IABCP can be an effective means of controlling refractory ventricular arrhythmia, allowing time for the institution of more definitive treatment.

Primary aortic valve replacement with allografts over twenty-five years: valve-related and procedure-related determinants of outcome.

OBJECTIVES: Allografts offer many advantages over prosthetic valves, but allograft durability varies considerably. METHODS: From 1969 through 1993, 618 patients aged 15 to 84 years underwent their first aortic valve replacement with an aortic allograft. Concomitant surgery included aortic root tailoring (n = 58), replacement or tailoring of the ascending aorta (n = 56), and coronary artery bypass grafting (n = 87). Allograft implantation was done by means of a "freehand" subcoronary technique (n = 551) or total root replacement (n = 67). The allografts were antibiotic sterilized (n = 479), cryopreserved (n = 12), or viable (unprocessed, harvested from brain-dead multiorgan donors or heart transplant recipients, n = 127). Maximum follow-up was 27.1 years. RESULTS: Thirty-day mortality was 5.0%, and crude survival was 67% and 35% at 10 and 20 years. Ten- and 20-year rates of freedom from complications were as follows: endocarditis, 93% and 89%; primary tissue failure, 62% and 18%; and redo aortic valve replacement, 81% and 35%. Multivariable Cox analyses identified several valve- and procedure-related determinants: rising allograft donor age and antibiotic-sterilized allograft for mortality; donor more than 10 years older than patient for endocarditis; rising donor age minus patient age, rising implantation time (from harvest to aortic valve replacement), and donor age more than 65 years for tissue failure; and rising donor age minus patient age, young patient age, rising implantation time, and subcoronary implantation preceded by aortic root tailoring for redo aortic valve replacement. Estimated 10- and 20-year rates of freedom from tissue failure for a 70-year-old patient with a viable valve from a 30-year-old donor and no other risk factors were 91% and 64%; the figures were 71% and 20% if the donor age was 65 years. The rates of freedom from tissue failure for a 30-year-old patient with a 30-year-old donor were 82% and 39%; the figures were 49% and 3% with a 65-year-old donor. Beneficial influences of a viable valve were largely covered by short harvest time (no delay for allografts from brain dead organ donors or heart transplant recipients) and short implantation time. CONCLUSIONS: Primary allograft aortic valve replacement can give acceptable results for up to 25 years. The late results can be improved by the use of a viable allograft, by matching patient and donor age, and by more liberal use of free root replacement with re-implantation of the coronary arteries rather than tailoring the root to accommodate a subcoronary implantation.

Impact of postangioplasty restenosis on comparisons of outcome between angioplasty and bypass grafting. Coronary Angioplasty versus Bypass Revascularisation Investigation (CABRI) Investigators.

Restenosis is a major limitation of percutaneous transluminal coronary angioplasty (PTCA). In this study, we assessed the impact of restenosis on PTCA with reference to coronary angioplasty bypass grafting (CABG). In the Coronary Angioplasty versus Bypass Revascularisation Investigation (CABRI) PTCA population, those who had restenosis were defined as those needing a second revascularization at a site revascularized at the initial procedure. The 1-year clinical outcome of the nonrestenotic group (n=437) was compared with those who underwent CABG (n=453). There was no difference in deaths. In the nonrestenotic PTCA group, the incidence of more infarctions was insignificant (relative risk [RR] 1.9, 95% confidence intervals [CI] 0.96 to 3.75, p=0.064), there was a much greater need for repeat revascularization (RR 8.6, CI 5.14 to 14.41, p <0.0005), and patients had a poorer angina status (RR 1.46, CI 1.01 to 2.13, p=0.046). Using 2 measures of coronary disease, the degree of pre- and postrevascularization disease was compared between groups. There were no differences in prerevascularization disease. However, using either measure, residual postrevascularization disease was more frequent in the nonrestenotic PTCA group. Restenosis only partially accounts for the greater morbidity seen after PTCA, compared with CABG, in multivessel disease. The greater likelihood of residual disease post-PTCA may contribute to this greater morbidity.

Simplified method for compression of femoral false aneurysms.

False aneurysm formation is a not uncommon complication of cardiac catheterization. Until recently, surgical repair was the only therapeutic option available when conservative management failed. However, Doppler-guided compression of the aneurysm has been advocated in recent years; the method requires prolonged indirect manual compression of the femoral artery aneurysm and is uncomfortable for both the patient and operator. In ten consecutive patients the use of Doppler-guided clamp placement and aneurysm compression for 60 min resulted in complete thrombosis of the aneurysm in eight, and only one patient required surgical repair. The procedure was well tolerated by all patients (analgesia was administered liberally). Eight patients were discharged within 24 h, one after 2 days and the single surgical patient remained an inpatient for 6 days. Doppler-guided clamp compression of false aneurysms is a safe, effective and cost effective method of managing these patients.

Late endothelial function of free and pedicled internal mammary artery grafts.

The internal mammary artery has greater long-term patency than the saphenous vein when used for coronary bypass grafting. Therefore, bilateral use of the internal mammary artery for grafting with the right internal mammary artery used as a "free" graft may result in improved graft survival. The study objectives were to compare the endothelial-dependent and -independent vasodilatory response in free and pedicled internal mammary artery grafts in patients who had previously undergone coronary surgery. Free (group 1, n = 8) and pedicled (group 2, n = 7) internal mammary artery grafts were studied by comparing the response to selective infusion of the endothelial-dependent vasodilator substance P (1.4 up to 22.4 pmol/min in doubling dose increments) followed by isosorbide dinitrate (2 mg over 2 minutes), in patients undergoing coronary angiography, 1 month to 6 years after coronary surgery. Maximal dilatory response to substance P was 8.7% +/- 1.8% in pedicled grafts compared with 8.8% +/- 2.3% in free grafts (p = not significant), with the dose response for both groups being similar. Infusion of isosorbide dinitrate produced only minimal further dilatation in both groups. No significant difference was found in endothelium-dependent and -independent vasodilatory response between free and pedicled internal mammary artery grafts, suggesting that the use of the free right internal mammary artery and other arterial grafts may enhance graft survival.