[Coronary revascularization surgery with arterial grafts]. / Cirugía de revascularización coronaria con injertos arteriales.

Coronary artery revascularization surgery is well established procedure throughout the world. The benefits are based on the blood perfusion through the implanted grafts distal to the coronary occlusions and continue as long as the grafts remains patent. The immediate success of this procedure is related to the surgical technique and the anatomical characteristics of the grafted coronary arteries. However, the long term results are mainly dependent on the type of grafts used. The modern era of myocardial revascularization started in the sixties with the use of saphenous vein grafts by Johnson and Favaloro. Alternative vascular conduits to the saphenous vein have been tried, and the internal mammary artery has become the first choice. In recent years, various publications have demonstrated the supremacy of the internal mammary artery over the saphenous vein when used as a single, bilateral, sequential of free graft. In order to obtain full myocardial revascularization, the use of alternatives to the internal mammary artery is required. The gastroepiploic artery, the inferior epigastric artery and the radial artery have been used as alternatives to the saphenous vein with the hope of obtaining long term results similar to the internal mammary artery.

Acute bicaval obstruction as a result of intracapsular haemorrhage in a right atrial myxoma: report of a case.

Right atrial myxomas are rare and presentation is characterised by the gradual onset of one or more of a triad of constitutional, obstructive, or embolic symptoms. We describe a case in which interstitial haemorrhage within a right atrial myxoma resulted in rapid expansion and presentation with features of rapidly progressing bicaval obstruction and atrial flutter. Transthoracic echocardiography failed to detect this tumour; however, transoesophageal echo clearly displayed it and gave information on its attachment and relations which proved to be valuable in the planning of its surgical excision.

An unusual case of supraventricular arrhythmia.

This case report describes the occurrence of a supraventricular arrhythmia in a patient with a large epiphrenic oesophageal diverticulum. The arrhythmia was precipitated by meals and was thought to result from pressure effects on the left atrium. Medical therapy did not control the arrhythmia. Excision of the diverticulum combined with oesophageal myotomy resulted in a dramatic relief of symptoms.

Omission of aspirin in patients following coronary artery bypass graft surgery.

Graft patency is a major factor contributing to the long-term results of coronary artery bypass graft (CABG) surgery. The systematic overview of the Antiplatelet Trialists' Collaboration provides unequivocal evidence that antiplatelet therapy reduces by nearly one-half the odds of coronary graft occlusion following CABG. We retrospectively reviewed patients undergoing CABG during 1993 at the Cardiothoracic Unit, Northern General Hospital, to determine the incidence of, and indications for, aspirin omission following CABG: 462 patients with isolated CABG, 75 patients with a combined CABG and a heart valve procedure and 21 patients with a combined CABG and other non-valve procedure. Thirty-six patients (7.5%) with isolated CABG and CABG combined with a non-valve procedure were not prescribed aspirin. The reasons for aspirin omission were categorized into three groups depending on whether omission was fully justified (group 1), possibly justified (group 2) or unjustified (group 3). Twenty-one patients were in groups 2 and 3, nine of whom were started on aspirin 2-6 weeks after discharge without any ill effect. Forty-two patients were discharged from hospital on a three month course of warfarin. Four months later four patients had died, 24 had changed to aspirin, 10 were still on warfarin and four were on neither drug. Aspirin was sometimes omitted without clear indications. Better provisions for supervision should be made by either the General Practitioner or Hospital Practitioner during the change-over period from oral anticoagulation to antiplatelet therapy in patients on a short course of warfarin.

Late onset tracheo-oesophageal fistula following a swallowed dental plate.

Swallowing dentures and dental plates has been a cause of distress among elderly patients. Tracheo-oesophageal fistula caused by a foreign body is rare and of the cases reported in the literature only one was due to a swallowed denture which resulted in a recurrent laryngeal nerve palsy [4]. We describe a delayed onset tracheo-oesophageal fistula due to a swallowed dental plate in a young patient.

The use of fresh blood to control severe haemorrhage associated with massive blood transfusion after cardiopulmonary bypass.

A 61-year-old man with severe factor XI deficiency presented for coronary artery bypass surgery. The clotting deficiency was corrected preoperatively with factor XI concentrate. Surgery resulted in severe postoperative haemorrhage of 55 liters of blood. This was managed successfully with a cell saver device (Haemonetics). Repeated platelet transfusions were ineffective in correcting the platelet dysfunction. The severe haemorrhage stopped suddenly after the infusion of 4 units of fresh blood. The case demonstrates how fresh blood can be useful in the management of severe haemorrhage after massive blood transfusion.

Venous bypass for surgical resection of renal carcinoma invading the vena cava: a new approach.

A new technique is described which facilitates the surgical removal of renal carcinoma from the inferior vena cava. The use of cardiopulmonary bypass with or without cardiac arrest has been advocated but with this procedure only the inferior vena cava is bypassed, using femoral and right atrial cannulation, assisted by a closed system electromagnetic centrifugal pump. In appropriate cases this less complex technique allows prolonged access to the inferior vena cava whilst providing equal protection from pulmonary embolisation and tumour dissemination; it also reduces morbidity, operating time, difficulty and cost when compared with cardiopulmonary bypass.

Acute renal failure due to profound haemolysis--an unusual complication of cusp rupture in cardiac bioprostheses.

Haemolysis due to prosthetic cardiac valves is well documented in the literature, with an increased incidence in mechanical prostheses as compared to bioprostheses. We report this unusual complication in two patients who developed profound haemolysis rapidly resulting in acute renal failure following cusp rupture in mitral Ionescu-Shiley valves. One of the patients developed irreversible renal failure in spite of successful reoperation, while renal function normalized in the second case.

A comparison of blood, crystalloid and oxygenated crystalloid cardioplegia solutions on myoglobin and creatine kinase release following cardiac surgery.

Oxygenated crystalloid cardioplegia was found not to produce better cardioprotection than blood or crystalloid cardioplegia, as assessed by myoglobin and creatine kinase MB (CPK-MB) isoenzyme, in patients undergoing coronary artery surgery. Myoglobin and CPK-MB levels were found to peak at 1 and 3 h, respectively, following release of the aortic cross-clamp. There was a good correlation between peak myoglobin and CPK-MB levels. CPK-MB of non-cardiac origin was found to represent a substantial proportion of total CPK-MB 4 h after the release of the aortic cross-clamp.

Late paraplegia as a consequence of intraaortic balloon pump support.

There have been several reports of paraplegia after intraaortic balloon counterpulsation in the surgical literature. In each instance, the paraplegia occurred during the period of counterpulsation support. We describe a patient in whom late paraplegia occurred three days after the removal of an intraaortic balloon catheter.

Simplified aortic cannulation.

Cannulation of the ascending aorta for cardiopulmonary bypass can be complicated by excessive bleeding or improper (too low) placement. A simple method of cannulation that avoids these problems is presented. This technique has been utilized in more than 1,000 patients without untoward complications.

Coronary artery surgery using inverted internal mammary artery.

A 56-year-old man requiring multiple coronary artery bypass grafts but without enough suitable vein was operated upon using the retrograde flow of the right internal mammary artery to supply to posterior descending coronary artery. Relief of angina and non-ischaemic areas on the scan with thallium-201 supports our intention to use this method when other techniques are not possible.

[Beneficial effect of morphine on the threshold of electrical fibrillation of the ventricle. Experimental study]. / Efecto beneficioso de la morfina sobre el umbral de fibrilación "eléctrico" del ventriculo.

The action of 2-3 mg/kg of morphine on the threshold of electrical fibrillation of the ventricle (TVF) in anesthetized dogs has been studied. The basal TVF was 10.5 +/- 4.9 mA, increased to 20.2 +/- 7.7 mA (P 0.005) with the administration of this drug. Comparatively, the effect of morphine on the TVF is similar to that of propranolol and bretilium and more effective than procainamide. The mechanism by which it acts is not well known. Perhaps it is due to a homogenization of refractory periods in the ventricle as well as a possible morphine-catacholamine interaction. Morphine in dosis of 2-3 mg/kg could occupy a place among the antiarrhythmic drugs of choice with antifibrillatory action, with important usefulness in the field of anestesiology of cardiopaths.

Counterpulsation in experimental cardiogenic shock with ventricular arrhythmias. The antiarrhythmic effect of morphine.

In two groups of dogs a cardiogenic shock was induced and their circulation assisted by counterpulsation. In the second group aside from the counterpulsation, 4 mgrs/Kg of morphine was administered when stable ventricular arrhythmias appeared. Morphine showed to eliminate the ventricular arrhythmias in three cases and lessened them considerably in one, permitting better assistance with a counterpulsator.

Long-term evaluation of venous tissue in the construction of cardiac valves.

We present the evolution of venous tissue, used as a mitral or tricuspid prosthesis or in the reconstruction of the right ventricular outlet tract, for periods of up to 18 months. A histological and hydrodynamic study is made of the valves after sacrificing the animals. The venous tissue showed fibrosis, structural disorganization, elastosis, elastorexis and, above all, intense calcification in heavy deposits. Since the venous tissue evolved toward fibrosis and calcification, its use is considered contraindicated.