Arteriovenous dialysis access-associated transvenous pacemaker infection.

Pacemaker (PM), implantable cardioverter defibrillator and cardiac resynchronization therapy devices also provide support to chronic hemodialysis patients with cardiac rhythm abnormalities. However, these devices can get infected. In general, device infection is either primary or metastatic spread from a distant source. Arteriovenous grafts are commonly used to provide dialysis therapy. Compared to a fistula an arteriovenous graft runs a higher risk of infection. In this analysis, we report 2 chronic hemodialysis patients who have been successfully receiving dialysis through an arteriovenous graft for approximately 2 years. Both had had a PM device for about the same duration. Access infection necessitated surgical removal of the arteriovenous graft in these patients. However, due to bacteremia (methicillin-resistant Staphylococcal aureus (MRSA)), infection spread to involve the transvenous PM leads in both patients. In 1 patient the infection also involved the PM pocket. Lead and wound culture confirmed MRSA in both patients. PM device and leads were removed in both patients. After the resolution of bacteremia, both patients received an epicardial pacemaker. None of the patients had valvular endocarditis. While dialysis was provided with a catheter, an arteriovenous fistula was planned. In conclusion, contamination of the transvenous PM device can occur due to hematogenous spread of infection from an infected arteriovenous graft. Epicardial instead of a transvenous PM might be the better option for such patients to provide long-term cardiac rhythm support.

Surgical management of aortic valve disease in elderly patients with and without coronary artery disease: influence on quality of life.

AIM: The feasibility of coronary artery bypass grafting (CABG) concomitant with aortic valve replacement (AVR) is well established. However, its impact on long-term patient-perceived quality of life (QoL) in the elderly remains undefined. METHODS: Retrospective analysis was conducted on 866 patients 65 years of age and over who underwent AVR between October 1976 and December 1999 with a Carpentier-Edwards porcine bioprosthesis. This cohort was divided between those who underwent isolated AVR (n=438) and those with AVR and concomitant CABG (AVR+CABG; n=428). Mean age was 77.0+/-6.1 years (range, 65 to 91) in the AVR group and 78.2+/-5.5 years (range, 65 to 93) in the AVR+CABG group. QoL was assessed with the Short Form-36 health survey for survivors at follow-up, which was 97% complete. RESULTS: Operative mortality (OM) was 6.2% (27/438) for the AVR group and 8.9% (38/428) for the AVR+CABG group (P=0.130). The occurrence of hospital complications (P=0.162) and postoperative length of stay (P=0.980) was similar for the 2 groups. Actuarial survival at 10 years was 37.1+/-3.4% for AVR and 38.7+/-4% for AVR+CABG patients (P=0.088). On multivariate analyses, CABG was not a predictor of either OM or long-term survival. QoL was similar for the 2 groups on the summary components: physical health (39.4+/-11.4 versus 40.2+/-12.1; P=0.461) and mental health (50.2+/-10.8 versus 51.9+/-10.1; P=0.103). CONCLUSIONS: Despite the presence of severe coronary artery disease, CABG preserved the long-term QoL in elderly patients undergoing AVR.

State of the science: pacemaker and defibrillator interference from wireless communication devices.

The use of wireless communication devices has increased rapidly, with current industry estimates of 50,000,000 subscribers of cellular telephone services, a number that is expected to double by the year 2000. Because wireless communication devices emit RF signals, they have the potential to interfere with implantable devices. The mechanism of interference and the magnitude of interference must be considered in terms of the type of wireless communication device being used and the characteristics of the individual implantable device that is exposed to the RF emission of the cellular phone. This article reviews the potential effects of wireless communication devices on implantable devices and makes initial recommendations for patients with implantable devices.

Bilateral internal mammary artery grafting in women: a 21-year experience.

BACKGROUND: Coronary artery bypass grafting traditionally has carried a higher mortality rate in women than in men. It remains the leading cause of death in women despite major advances in diagnosis and treatment over the past 2 decades. METHODS: A retrospective analysis was conducted to identify risk factors that adversely influence hospital mortality, morbidity, and long-term clinical results in women undergoing bilateral internal mammary artery grafting. From January 1972 through October 1994, 327 consecutive women received bilateral internal mammary artery grafts and supplemental vein grafts. Patient age ranged from 32 to 84 years (mean, 65.7 years). There were 262 patients (80.1%) with three-vessel disease; 71 (21.7%) had substantial (> 50%) stenosis of the left main coronary artery, 65 (19.9%) had a moderately reduced (0.30 to 0.50) ejection fraction, and 11 (3.4%) had a severely reduced (< 0.30) ejection fraction. Preoperatively, 316 patients (96.6%) were in New York Heart Association class III or IV. RESULTS: There were 1,016 coronary artery grafts (mean, 3.1 per patient). The overall hospital mortality rate was 3.4% (11 of 327). Postoperative complications included myocardial infarction in 18 patients (5.5%), stroke in 5 (1.5%), pulmonary insufficiency in 11 (3.4%), reoperation for bleeding in 7 (2.1%), and sternal infection in 8 (2.4%). Independent predictors of operative death were postoperative cardiac arrest (p < 0.001), use of intraaortic balloon pump (p < 0.001), and reoperation for bleeding (p < 0.050). Follow-up was completed on 316 hospital survivors (100%) and ranged from 6 months to 21 years (mean, 5.1 years). Actuarial survival (mean +/- standard error of the mean) was 90.5% +/- 1.9% at 5 years and 65.6% +/- 6.1% at 10 years. At follow-up, 252 patients (94.0%) were asymptomatic in New York Heart Association class I, and 12 (4.5%) were in class II. CONCLUSIONS: This longitudinal study demonstrates that bilateral internal mammary artery grafting, though technically demanding, can be achieved in women with low hospital mortality and morbidity rates. Patients experienced reduced late cardiac events, excellent functional improvement, and enhanced long-term survival.

Determinants of operative mortality in octogenarians undergoing coronary bypass.

BACKGROUND: The elderly segment of the population is increasing rapidly, and surgeons are being asked to consider patients more than 80 years old as candidates for coronary bypass. The objective of this study was to identify risk factors that may adversely affect mortality as well as analyze functional outcomes and survival in octogenarians undergoing coronary bypass. METHODS: From July 1989 through February 1994, 300 consecutive patients 80 years of age and older underwent coronary artery bypass grafting. There were 176 men (58.7%) and 124 women (41.3%) with a mean age of 80.9 years (range, 80 to 99 years). Preoperatively, 274 patients (91.3%) had disabling angina, 76 (25.3%) had left main coronary stenosis greater than 50%, and 293 patients (98.3%) were in New York Heart Association class III or IV. RESULTS: The overall hospital mortality was 11.0% (33/300) with an elective mortality of 9.6% (23/240), urgent mortality of 11% (5/45), and emergent mortality of 33.3% (5/15). Significant independent predictors of operative mortality were preoperative renal dysfunction, postoperative pulmonary insufficiency, postoperative renal dysfunction, use of intraaortic balloon pumping, and sternal wound infection. The actuarial survival for patients discharged from the hospital was 74.6% +/- 5.6% (standard error of the mean) at 54 months. CONCLUSIONS: A favorable outcome may be expected when coronary artery bypass grafting is performed in patients 80 years of age or older with severe angina.

Coronary bypass grafting in the elderly. Single versus bilateral internal mammary artery grafts.

A surgical experience between October 1983 and December 1990, with 1467 consecutive patients 65 years of age and over, was used to compare patients receiving single internal mammary artery grafts (n = 736) with those receiving bilateral internal mammary artery grafts (n = 731). The mean age in the single-graft group was 73.2 years and 70.9 years in the bilateral-graft group (p < 0.001). Various clinical parameters were analyzed that revealed that the single-graft group had more women and more patients with unstable angina, a history of previous myocardial infarction, and emergency surgery (p < 0.05). There was no significant difference in cigarette smoking, hypertension, diabetes mellitus, hyperlipidemia, triple vessel coronary artery disease, left main coronary artery stenosis, or left ventricular function between the two groups. Hospital mortality for the single-graft group was 6.4% (47 patients) and 3.1% (23 patients) for the bilateral-graft group (p < 0.004). No significant difference was observed between the groups in the rate of reoperation for bleeding, sternal infection, respiratory failure, stroke, or perioperative infarction. Follow-up was obtained in 663 hospital survivors (96.4%) in the single-graft group and in 691 (97.7%) in the bilateral-graft group. Mean follow-up in the single-graft group was 42.5 months (range, 1 to 92.4 months) and 43.0 months (range, 1 to 90.3 months) in the bilateral-graft group. In the single-graft group, survival was 60.7% +/- 4.8% (+/- standard error of the mean) at 8 years (60 patients at risk); it was 67.9% +/- 8.1% (18 patients at risk) for the bilateral-graft group (p < 0.028). This comparative study demonstrates that bilateral internal mammary artery grafting can be accomplished in elderly patients with low operative risk and hospital morbidity. Moreover, patients in both groups had a reduction in cardiac events and significant functional improvement.

Bilateral internal mammary artery grafts in patients with left main coronary artery disease.

The use of the internal mammary artery (IMA) in myocardial revascularization has been expanded with bilateral and sequential grafting. However, its application in the presence of left main coronary artery stenosis (LMCAS) has not been well established. From September 1983 through December 1990, 280 patients with LMCAS greater than 50% were revascularized (3.4 mean grafts per patient) with bilateral IMA and saphenous vein grafts. Eighty-one were sequential IMA grafts. There were 234 males (83.6%) and 46 females (16.4%) with a mean age of 64.4 years (range 39 to 84 years). Preoperatively, there were six patients (2.1%) in New York Heart Association (NYHA) Class I, 30 patients (10.7%) in Class II, 130 patients (46.4%) in Class III, and 114 patients (40.7%) in Class IV. Fifty-six patients (20.0%) had an ejection fraction less than 50%. Intraaortic balloon counterpulsation was used preoperatively in 26 patients (9.3%) and intraoperatively in 11 patients (3.9%). There were four hospital deaths (1.4%). Hospital complications included: reoperation for bleeding, 7 patients (2.5%); pulmonary insufficiency, 21 patients (7.5%); perioperative infarction, 14 patients (5.0%); and stroke, 4 patients (1.4%). Follow-up was obtained in 276 hospital survivors (100.0%) with a mean of 33.4 months. There were 20 late deaths (7.1%): seven cardiac related and 12 noncardiac related. Postoperative assessment reveals substantial functional improvement. These results furnish evidence that bilateral IMA grafts can be accomplished with a low operative risk and can provide excellent functional results in patients with LMCAS.