Aprotinin for patients exposed to clopidogrel before off-pump coronary bypass.

To verify whether low-dose aprotinin reduces blood loss and blood product usage in patients with clopidogrel exposure within 5 days before off-pump coronary artery bypass, 51 patients with clopidogrel exposure were randomized in a double-blind fashion to receive low-dose aprotinin (25 patients), or placebo (26 patients). The baseline characteristics and number of distal anastomoses in the patients in each group were comparable. Time between the last dose of clopidogrel and start of the operation was similar in both groups, as was mean left ventricular ejection fraction. Chest tube drainage, blood product usage, and reoperation rate were significantly higher in the placebo group. In patients with unstable angina and recent clopidogrel exposure who are undergoing off-pump coronary artery bypass, intraoperative administration of low-dose aprotinin is recommended to reduce blood loss and transfusion requirements.

False aneurysm of the left ventricle following myocardial infarction: an unusual location.

A false aneurysm of the left ventricle that is in fact a contained rupture is rare. False aneurysms have been reported to be mostly at the posterior-basal and rarely at the apical segments of the left ventricle. Early surgical intervention is recommended because of the risk of rupture. This report describes the successful surgical management of two patients with false aneurysms of the left ventricle, located at the lateral wall and the inferior wall following a recent inferior and lateral-wall myocardial infarction.

Association of edge-to-edge repair to De Vega annuloplasty for tricuspid incompetence.

BACKGROUND: We aimed to analyze whether association of edge to edge repair to De Vega annuloplasty would result in better results in patients with severe TR. METHODS: Fifty seven patients with TR>/=3 were randomized to undergo modified De Vega alone (group D, 28 patients) or associated with edge to edge repair (group E, 29 patients). All patients had preoperative and two postoperative (early and mid-term) echocardiography. The tricuspid regurgitation, diameter of tricuspid valve annulus, pulmonary artery pressure and right ventricular EF were recorded. RESULTS: Early postoperative echocardiography indicated less residual TR in group E while other parameters were comparable. The mean follow-up period was 28.2+/-5.4 months. Mid-term postoperative mean TR was 1.9+/-0.8 vs. 1.0+0.4 (p=0.0384) indicated less redevelopment of TR in group E. Additionally TVA re-dilatation was found more prominent in group D. One patient in group D underwent operation for recurred TR. CONCLUSION: Our results suggested that association edge-to-edge technique to De Vega annuloplasty has resulted in reduced residual TR and less incidence of recurrence of TR and TVA dilatation.

Off-pump CABG in diabetic patients: does insulin dependency matter?

BACKGROUND: We aimed to analyze influence of insulin dependency on short-term outcomes after OPCAB in patients with diabetes. METHODS: Retrospective cohort study was planned based on chart review. Study population consisted of 148 diabetic cases (63 insulin-dependent diabetics in group I and 85 non-insulin-dependent diabetics in group II). Patients' preoperative data and risk factors for adverse outcomes are analysed. The primary endpoint was all causes of mortality during the in-hospital course. Preestablished secondary endpoints included all major postoperative complications, including non-fatal acute myocardial infarction, non-fatal stroke, sepsis, shock, mediastinitis, respiratory insufficiency, and renal insufficiency, and minor postoperative complications, including mechanical ventilation for more than 24 hours, inotropic support, reoperation for bleeding, and necessity of blood transfusion. Additional analysis was performed on the duration of stay in the intensive care unit and overall hospital stay. RESULTS: Group I patients were significantly more likely to have hypertension (87.3% versus 82.5%, p=0.023), they also had a trend toward higher prevalence of hypercholesterolemia (71.4% versus 68.6%, p=0.092) and body mass index (28.1+/-4.2 versus 26.9+/-3.7, p=0.085). Angiographic characteristics and number of distal anastomosis were similar in the two groups. There was no significant difference in mortality during the in-hospital course as the primary endpoint. However, analysis in secondary endpoints revealed that group I patients were significantly more likely to have stroke (3.1% versus 2.3%, p=0.027), sternal wound infection (4.7% versus 3.4%, p=0.036) and atrial arrhythmia (28.3% versus 20.9%, p=0.021). Moreover, group I patients were significantly more likely to stay longer than 2 days in ICU (14.2% versus 11.6%, p=0.038). Higher prevalence of renal dysfunction was also observed in group I patients (7.9% versus 6.9%, p=0.069). CONCLUSION: Similar to insulin dependent diabetes who had on-pump CABG, insulin dependent diabetes develop higher rate of major postoperative complications and stay longer in ICU after off-pump CABG.

Coronary by-pass for bad ventricle; adoption of "hybrid-pump" bypass.

BACKGROUND: The outcomes of on-pump and hybrid-pump bypass surgery in patients with depressed left ventricular function (EF<30%) were analyzed. METHODS: 109 patients with preoperative left ventricular ejection fraction of <30% and bypassable circumflex coronary disease were randomized in a double blind fashion to undergo hybrid-pump (combination of off-pump and on-pump) procedure (54 patients), or on-pump coronary bypass (55 patients). In patients who underwent hybrid-pump procedure only circumflex system was bypassed on-pump to shorten CPB and myocardial ischemic time. Pre- peri and postoperative variables were analyzed. RESULTS: Mean LVEF 24.4 +/- 4.8%. The patients in hybrid-pump group received less graft than others, but difference was not significant. Duration of the surgery was not different statistically between hybrid-pump and on-pump groups. A longer intraoperative duration of ischemia and extra corporeal circulation was found in on-pump group. Significant improvement in the postoperative course such as shorter mechanical ventilation, less catecholamines and IABP usage, less ICU and hospital stay, less stroke, less need for hemodyalisis and most importantly less hospital mortality was observed in hybrid-pump group. CONCLUSION: Shortening the CPB and myocardial ischemic time and avoiding related problems, adoption of hybrid-pump strategy, in patients with severely impaired LVEF and bypassable circumflex coronary disease results in better outcome than conventional on-pump bypass.

Off-pump coronary bypass for patients with concomitant malignancy.

BACKGROUND: The effectiveness and advantages of off-pump coronary artery bypass (OPCAB) for patients with concomitant malignant neoplastic disorders were analyzed. METHODS AND RESULTS: The study group comprised 368 patients who underwent OPCAB and of them 18 had concomitant malignant neoplastic disease: 14 with solitary malignant disease, 4 with low-grade lymphocytic malignancies. The age of the patients ranged from 49 to 72 years (mean 61). The mean left ventricular ejection fraction was 46.4% (range: 35-60%) and the mean number of grafts was 2.4+/-0.9. The left internal mammary artery was used in 12 patients (75%). Mean blood loss was 420+/-64 ml and the average requirement for blood transfusion was 1.1+/-0.2 units. There was no postoperative infection or in-hospital mortality. The mean length of hospital stay was 6.4+/-1.3 days. Mid-term follow-up was completed (100%) and the mean follow-up period was 22.6+/-4.1 months. All patients with a solitary malignancy underwent subsequent non-cardiac surgery with a mean interval of 16.4+/-3.3 days. Mid-term survival was 83.4%. Freedom from late cardiac events (angina, myocardial infarction, percutaneous transluminal coronary angioplasty) that required hospital admission was 92.3%. CONCLUSION: These results support the effectiveness of OPCAB, mostly as a bridge to safe non-cardiac surgery that can be crucial for long-term survival.

Off-pump coronary endarterectomy in high-risk patients.

The outcome of off-pump endarterectomy in patients with diffuse coronary artery disease and increased risk factors for cardiopulmonary bypass was reviewed. Thirty-eight procedures were carried out in 32 patients (21 men and 11 women) aged 59 to 78 years (mean, 69 years). Mean left ventricular ejection fraction was 38.6% (range, 24% - 55%). The number of grafts per patient was 2.6. The left internal mammary artery was used in 29 patients (91%). Endarterectomy was performed on the right coronary artery and its branches (18), the left anterior descending artery (15), diagonal branch (2), and the circumflex system (3). Overall operative mortality was 3.1%. Perioperative myocardial infarction occurred in 6.2%. Follow-up was complete in 30 patients (94%). The mean follow-up period was 14 +/- 3.3 months. Late survival was 93%. Freedom from cardiac events that required hospital re-admission was 89%. Freedom from angioplasty of the endarterectomized vessel was 96%. These findings indicate that off-pump endarterectomy can be performed with good results in patients with diffuse coronary artery disease.

Impact of clopidogrel on postoperative blood loss after non-elective coronary bypass surgery.

The aim of this study was to evaluate the effects of clopidogrel on blood loss and blood and blood products usage following CABG. One hundred and ninety-six patients underwent urgent or emergent CABG, 182 of those met with inclusion criteria, 28 patients had clopidogrel exposure (group 1), 49 patients had both ASA and clopidogrel exposure (group 2), and 68 patients had ASA exposure (group 3) within a week of operation. The remaining 37 patients were on no antiaggregant therapy (group 4). Total chest tube drainage during the first 24 h, the incidence of reoperation for bleeding, blood and blood products usage, and the early outcome (duration of mechanical ventilation, the intensive care unit stay and total hospital stay), were assessed. Total chest tube drainage was significantly higher in the patients with clopidogrel exposure and increased amount of transfusions with blood products were also observed in those patients. The patients with clopidogrel exposure required significantly more reoperation for bleeding. The duration of controlled ventilation and intensive care unit stay were also significantly longer in the patients with clopidogrel exposure. Our results support the recent history of clopidogrel treatment associated with increased blood loss, transfusion and reoperation requirement after CABG.

St. Jude medical valve in pulmonary position: anticoagulation and thrombosis.

Between 1979 and 1985, 5 patients underwent pulmonary valve replacement with a St. Jude Medical valve. During follow-up ranging from 30 months to 18 years, there were 6 episodes of valve thrombosis in 4 patients. Three episodes were treated by thrombolysis. Reoperation was necessary in 3 patients. Although the St. Jude Medical valve in the pulmonary position can occasionally function long-term without anticoagulation, these cases show the high risk of thrombosis and need for anticoagulation.