Cerebral perfusion during off-pump coronary artery bypass grafting.

PURPOSE: It is still unclear whether cerebral perfusion is affected during off-pump coronary bypass grafting (OPCABG). We investigated the predictive value of the neurobiochemical markers of brain damage and cerebral perfusion in relation to early neuropsychological outcome after OPCABG. METHODS: We performed OPCABG in ten patients (mean age, 63.4 +/- 5.5 years). A 5.5 F oximetric catheter was placed in the jugular bulb to continuously measure jugular oxygen saturation (SjO(2)) during OPCABG. We also examined the activity of daily living (ADL) index and performed the Mini-Mental State Examination (MMSE) to assess neuropsychological state preoperatively and 7 days postoperatively. Venous serum levels of neuron-specific enolase (NSE) and brain-specific creatine kinase (CK-BB) were measured preoperatively and 24 h after skin closure. RESULTS: The mean arterial blood pressure and the SjO(2) during anastomosis of the left circumflex coronary artery (Cx) were significantly lower than that of the left anterior descending coronary artery (LAD) (P < 0.001). None of the patients died. There was no transient or permanent neurologic deficit. Cognitive decline was evident in two patients with a low SjO(2) and a high postoperative NSE level. The postoperative CK-BB value was normal in all patients. CONCLUSIONS: Monitoring intraoperative continuous cerebral oxygen desaturation and postoperative NSE levels could be useful for predicting early neuropsychological outcome after OPCABG.

Autologous blood donation before elective off-pump coronary artery bypass grafting.

PURPOSE: Preoperative autologous blood donation reduces exposure to homologous blood transfusions in cardiac surgery. The purpose of this study was to ascertain the volume of predonated autologous blood needed to avoid homologous blood transfusion in scheduled off-pump coronary artery bypass grafting (off-pump CABG). METHODS: Fifty-six patients underwent scheduled off-pump CABG between January 1999 and December 2000. These patients all donated either 400 ml (group 1, n = 33) or 800 ml (group 2, n = 23) of autologous blood before operation. These patients donated at a rate of 400 ml per week. All patients were given an equal volume of saline solution at the time of autologous donation. RESULTS: There were no significant differences in the mean age, mean body weight, mean preoperative hematocrit values, mean graft number, or mean volume of intraoperative blood loss between groups 1 and 2. There was a significant difference in the mean postoperative day-7 hematocrit value (33.6% +/- 1.3% vs 39.3% +/- 1.3%, P << 0.05). The rates of avoiding homologous blood transfusion were 63.6% in group 1 and 100% in group 2 ( P << 0.05). CONCLUSIONS: Autologous blood transfusion is effective for reducing the homologous blood requirement. We believe that an 800-ml predonation is sufficient to avoid homologous blood transfusion in scheduled off-pump CABG; furthermore, patients with cardiovascular disease, including severe coronary artery disease, should be administered saline along with the blood donation.

Surgical case of aortic root and thoracic aortic aneurysm after the Wheat procedure.

A 52 year-old man underwent aortic valve replacement and ascending aortic replacement (Wheat procedure) for acute dissection (Stanford type A) and aortic regurgitation (grade 3/4). At that time, the aortic root was slightly dilated at about 45 mm and the descending aorta was within a normal range at about 35 mm. Forty months after the initial operation, a follow-up chest enhanced computed tomography showed an aortic root aneurysm about 60 mm in diameter, a thoracic aortic aneurysm about 70 mm in diameter and chronic aortic dissection. First we performed the Bentall procedure, innominate artery and left common carotid artery replacement by 12 mm, and 10 mm Hemashield grafts during selective cerebral perfusion. After 10 weeks, we carried out aortic arch, descending aorta and left subclavian artery replacement. The postoperative course was uneventful and postoperative examination demonstrated a good surgical result. Histological findings of the aortic aneurysm wall showed cystic medial necrosis, but Marfan's syndrome was excluded clinically. We could diagnose aortic root aneurysm by regular follow-up chest enhanced computed tomography (CT) and echocardiography. Therefore, cases with slight dilation of the aortic root in the Wheat procedure should undergo regular follow-up evaluation by chest enhanced CT and echocardiography.

Aortic root replacement using composite valve graft in patients with aortic valve disease and aneurysm of the ascending aorta: twenty years' experience of late results.

The purpose of this study was to evaluate the clinical outcome of composite valve graft replacement in 193 patients with aortic valve disease and aneurysm of the ascending aorta from January 1980 to June 1999. The clinical outcome was compared between the patients diagnosed with Marfan syndrome (M group) and those without Marfan syndrome (non-M group), between those with aortic dissection (AD group) and without dissection (non-AD group), between 2 different techniques for coronary artery reattachment (modified Bentall [mB] and modified Piehler [mP]), and between the time of operation (1980-1989 and 1990-1999). Long-term outcome of this procedure was almost satisfactory with actuarial survival of 71.5 +/- 4.4% at 10 years and freedom from reoperation of 76.5 +/- 4.4% at 10 years. Freedom from cardiovascular events and freedom from reoperation were significantly lower in the M group and AD group than in the non-M and non-AD groups. Also, actuarial survival was significantly higher in the latter 10 years compared with the former 10 years. It was concluded that the improvement of perioperative management and proper selection of the technique for coronary artery reattachment could have improved the clinical outcome. In patients with Marfan syndrome or aortic dissection, there still remains a higher risk of cardiovascular event and future reoperation. Extensive aortic reconstruction or staged operation should be performed in such patients.

Arch-first technique for aortic arch operation using branched graft.

To compare the arch-first technique with conventional aortic arch reconstruction 19 patients were randomly assigned to either procedure. Nine patients underwent the arch-first technique (group A) and 10 underwent the conventional technique (group B). There were no hospital deaths and no significant differences between groups in terms of intraoperative bleeding or the duration of operation cardiopulmonary bypass aortic crossclamping recovery from anesthesia or intensive care. The mean duration of retrograde cerebral perfusion via the superior vena cava was significantly shorter in group A (41.7 +/- 10.4 min) than group B (63.9 +/- 10 min). Transient neurologic dysfunction was noted in 4 (44%) patients in group A 6 (60%) in group B postoperatively but there was no permanent neurologic dysfunction in either group. The arch-first technique makes it possible to reduce the duration of cerebral ischemia retrograde cerebral perfusion via the superior vena cava reestablish antegrade cerebral perfusion earlier without damaging severely atheromatous arch vessels or conducting retrograde cerebral perfusion via a femoral artery. This technique has the potential to reduce the incidence of neurologic dysfunction.