Saphenous vein coronary bypass graft revisited.

To establish a benchmark for the clinical efficacy of PTCA and the IMA graft in our institution, the data from 79 patients who underwent isolated SVBG to the LAD between July, 1971, and December, 1984, were analyzed. Follow-up averaged 96.16 months/patient. Actuarial freedom from reoperation was 100% at 12 months, 95% at 60 months, and 89.4% at 120 months. Actuarial freedom from cardiac death was 100% at 12 months, 94% at 60 months, and 87% at 120 months. Actuarial freedom from an LAD graft failure myocardial event was 100% at 12 month, 94% at 60 months, and 77% at 120 months. Our SVBG failure rate did increase from 1.2%/year during the first 5 years to 3.4%/year during the second 5 years. We are presently selectively employing IMA grafts to the LAD. Our results with the SVBG and the palliative nature of all coronary artery bypass graft procedures remove the imperative to always use the IMA. Individual patient considerations such as age, clinical stability, IMA flow, and the residual anatomy for the potential reoperation are important considerations.

Long-term experience with mitral valve replacement: an evolving strategy for prosthesis selection.

MVR was examined in 181 patients undergoing 188 consecutive operations during a 12 1/2-year observation time. Hospital mortality for MVR without aortic valve disease was 7 of 156 or 4.5% and was independent of the valve type employed and the presence of coronary artery pathology. Late cardiac mortality in isolated MVR was significantly greater in those patients receiving a Starr-Edward 6120 prosthesis when compared to those receiving an MPX. The presence of coronary artery pathology, however, defines the patient subgroup with the poorest late survival. Tissue durability has not significantly altered late survival after MPX. However, the actuarial analysis of tissue failure reveals important increases in tissue failure incidence 5 years after placement. Although MPX is our prosthesis of choice for MVR, limited tissue durability creates an important subgroup for judicious use of a mechanical prosthesis. We conclude that no valve type should be championed as "the valve" for all patients undergoing MVR. The selection of a valve for MVR remains a difficult judgment which must be tempered by the patients age, history of previous operations, severity of his present illness, and the feasibility of a second MVR.

Autogenous tissue reconstruction in the management of infected prosthetic grafts.

Infection is the most dreaded complication associated with implantation of a prosthetic arterial graft. Although remote bypass followed by complete removal of the infected prosthesis has proven to be a satisfactory method of treatment, in certain instances remote bypass alone is not feasible and other modes of surgical treatment must be employed. This report describes the use of autogenous reconstructions within the infected field, including endarterectomy and replacement of the infected graft with arterial or venous autografts in 24 patients. The key approach in these patients was (1) accurate preoperative assessment of the extent of graft infection, (2) aggressive surgical efforts to remove all infected prosthetic material, and (3) autogenous reconstructions within the infected field to supply critical vascular beds. Three patients died, for a mortality rate of 13%. There were no strokes and only two amputations. Suture lines involving autogenous tissue healed, even when in an infected field. In the aortofemoral group, preservation of aortic continuity is very desirable, when possible. We believe that these techniques provide the maximal potential for salvage of life and limb in the management of this dreaded vascular complication.

Canine gallbladder bile. Effects of proximal gastric vagotomy, truncal vagotomy, and truncal vagotomy with pyloroplasty on volume and composition.

Three groups of four dogs each underwent proximal gastric vagotomy, truncal vagotomy, or truncal vagotomy with pyloroplasty. Two dogs had sham operations. Gallbladder bile was aspirated and measured. Aliquots were cultured and assayed for cholesterol, phospholipid, and bile salts initially and at subsequent laparotomies. Both truncal vagotomy groups showed marked increases in aspirate volume at subsequent laparotomies. The sham and proximal gastric vagotomy groups showed a small initial decrease in mean aspirate volume without further significant changes. When the bile assay data were plotted on triangular coordinates, all point for all groups remained well within the area of cholesterol solubility. Nevertheless, two dogs in each truncal vagotomy group were found to have gallstones. No stones were found in the sham and proximal gastric vagotomy groups. Proximal gastric vagotomy appears to preserve fasting gallbladder bile volume and does not alter bile composition in the dog.