Concomitant occlusive disease of the coronary arteries and great vessels.

BACKGROUND: Although an increasing number of elderly and high-risk patients, including those with generalized atherosclerosis, are undergoing coronary revascularization, few reports exist regarding the management of patients who have both occlusive disease of the great vessels and coronary artery disease. METHODS: Between 1972 and 1996, 31 consecutive patients (mean age, 56.5 years; 74% men) with multivessel coronary artery disease and symptomatic occlusive disease of the great vessels (25 single-vessel, 80.6%; 6 multiple-vessel, 19.4%) had 40 great vessels reconstructed by transthoracic bypass (n = 17, 42.5%), transthoracic endarterectomy (n = 8, 20%), or extrathoracic bypass (n = 15, 37.5%). All patients had simultaneous coronary artery bypass grafting (mean, 2.6 grafts per patient), and 8 patients had 10 distal carotid bifurcation endarterectomies (6 staged, 4 simultaneous). RESULTS: The early primary patency rate was 100%, and symptoms resolved completely in all 31 patients. There was 1 in-hospital death (3.2%) in a patient who had a respiratory arrest 11 days after operation. Perioperative morbidity included two myocardial infarctions (6.5%) and one opposite-hemisphere, embolic stroke (3.2%). Long-term follow-up of the 30 survivors (167.4 patient-years; mean, 5.6 years per patient) documented 5- and 10-year actuarial survival rates of 88.6% and 60.4%, respectively, with a 100% late brachiocephalic primary patency rate. Ten-year actuarial rates of freedom from the following events were as follows: death, 60.4%; myocardial infarction, 82.5%; stroke, 90.9%; percutaneous transluminal coronary angioplasty or redo coronary artery bypass grafting, 95.2%; and vascular operation or amputation, 78.4%. CONCLUSIONS: Depending on the anatomic distribution of the disease, an integrated approach to great vessel reconstruction that incorporated transthoracic and extrathoracic approaches and techniques of endarterectomy and bypass resulted in few adverse outcomes and excellent long-term patency. Simultaneous revascularization of the great vessels and coronary arteries can produce immediate and long-term, symptom-free outcome with acceptably low operative risk.

Is an integrated approach warranted for concomitant carotid and coronary artery disease?

BACKGROUND: The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial. METHODS: Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis > 70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and carotid endarterectomy were simultaneously performed in 255 patients (49.8%) with unstable angina. In group 2 (staged approach), carotid endarterectomy was performed before coronary revascularization in 257 patients (50.2%) without unstable angina. RESULTS: Before 1986, the incidence of stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101) have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate and multivariate predictors of adverse outcome were primarily heart-related (reoperation, intraaortic balloon use, ejection fraction < 0.50, and angina grade 4 for death; age > 70 years and congestive heart failure for stroke). CONCLUSIONS: Despite highly selected populations, contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations.

Integrated cardiac care.

In 1984 physicians at the Texas Heart Institute developed Cardiovascular Care Providers Inc, the first packaged-pricing plan for cardiovascular surgery. Under this arrangement, all services, including physician and hospital charges, are covered by a global payment package (bundled service). The resulting flat fee is lower than the sum of the individual charges. Since November 1984 the plan has been offered to the non-Medicare (less than 65 years old) population through contracts with self-insured corporations, prepaid health plans, union trusts, and foreign governments. In 1993 it was extended to Medicare patients who require coronary artery bypass grafting. Our experience has shown the plan lowers cost, increases patient access, allows payers to forecast their expenses, and streamlines the billing process, while maintaining a high quality of care and enabling patients to choose their own providers. Our success with this approach is attributed not only to the plan's simplicity, but also to the fact that it is physician directed and organ specific, involving many related specialties. Equally important keys to success include our hospital's large patient population and extensive database. Similar packaged-pricing plans have been adopted by several other cardiovascular centers. The approach is now being evaluated by Medicare in 6 other hospitals nationwide. With time, this approach is likely to become an increasingly popular reimbursement option.

CardioVascular Care Providers. A pioneer in bundled services, shared risk, and single payment.

In 1984, physicians at the Texas Heart Institute developed CardioVascular Care Providers, Inc., the 1st packaged pricing plan for cardiovascular surgery. Under this arrangement, all services (including physician and hospital charges) are covered by a global payment package (bundled service). The resulting flat fee is lower than the sum of the individual charges. Since November 1984, the plan has been offered to the non-Medicare (< 65-year-old) population through contracts with self-insured corporations, prepaid health plans, union trusts, and foreign governments. In 1993, it was extended to Medicare patients who require coronary artery bypass grafting. Our experience has shown that the plan lowers costs, increases patient access, allows payers to forecast their expenses, and streamlines the billing process, while maintaining a high quality of care and enabling patients to choose their own providers. Our success with this approach is attributed not only to the plan's simplicity but also to the fact that it is physician-directed and organ-specific, involving many related specialties. Equally important keys to success include our hospital's large patient population and extensive database. Similar packaged pricing plans have been adopted by several other cardiovascular centers. The approach is now being evaluated by Medicare in 6 other hospitals nationwide. With time, this approach is likely to become an increasingly popular reimbursement option.

Congenital malformations of the coronary arteries: the Texas Heart Institute experience.

Coronary artery anomalies, some of which are considered clinically insignificant, can be associated with other congenital heart defects, myocardial ischemia, and reduced life expectancy. We conducted a retrospective study to determine the efficacy of surgical treatment in 191 patients who had a total of 202 coronary artery anomalies, which were classified as anomalies of origin (88 patients), termination (93), or distribution (10). Of the 88 patients with anomalies of origin, 60 had a coronary artery arising from the pulmonary artery, 18 had a right coronary artery arising from the left anterior descending artery, and 10 had a coronary artery arising from the contralateral sinus of Valsalva. All patients with an anomaly of termination had a coronary arteriovenous fistula, and all patients with an anomaly of origin had a single coronary artery. The diagnostic and operative techniques for each of the defects are evaluated. Based on our experience, early diagnosis and surgical intervention can yield satisfactory results in patients with coronary artery anomalies, with most experiencing relief of symptoms. The operative procedures were associated with a low early and late mortality; in addition, few patients experienced complications.

Supravalvar aortic stenosis: a 29-year review of surgical experience.

Between February 1960 and August 1989, 73 consecutive patients underwent surgical correction for supravalvar aortic stenosis (SVAS) at the Texas Heart Institute. There were 43 male (59%) and 30 female patients (41%) ranging in age from 5 days to 27 years (mean age, 12 years). Preoperatively, 8 patients were in New York Heart Association functional class I, 43 in class II, 18 in class III, and 4 in class IV. Of the 73 patients, 62 had localized SVAS and 11 (15%), diffuse SVAS. For all procedures, patients were placed on cardiopulmonary bypass. Those with localized SVAS were successfully treated with patch aortoplasty, whereas those with diffuse SVAS required either an apicoaortic conduit or extensive end-arterectomy with extended patch aortoplasty. There were eight early deaths (less than or equal to 30 days postoperatively) (11%) and four late deaths (greater than 30 days postoperatively) (6%) in a follow-up period ranging from 2 months to 28 years. Sixteen patients (25%) underwent one or more additional operations in the follow-up period. Postoperatively, there were 44 patients in New York Heart Association functional class I and 17 in class II. Preoperative functional class III and class IV (p less than 0.0005), diffuse SVAS (p = 0.05), and the presence of associated congenital defects (p less than 0.01) were important determinants of death.

Aneurysm of an aortocoronary saphenous vein bypass graft presenting as an anterior mediastinal mass.

Fifteen years after aortocoronary bypass surgery, a 52-year-old asymptomatic man was found to have a large anterior mediastinal mass. Angiographic studies showed no evidence that a vascular structure was responsible. At operation, a saphenous vein graft to the left anterior descending artery was found to be affected by a large thrombus-filled aneurysm. This is one of the few known cases in which such an aneurysm has presented as a mediastinal mass.

Surgical management of extracranial carotid artery aneurysms: report of 17 cases.

This article reviews the operative techniques, results, and complications associated with the treatment of 17 extracranial carotid artery aneurysms encountered in an overall experience of 6,096 carotid endarterectomies during a 24-year period. All 17 patients were operated upon because of severe symptoms and the potential for stroke. Eight patients underwent an aneurysmorrhaphy with Dacron-patch angioplasty; 7 had resection of the aneurysm, with end-to-end anastomosis and Dacron-patch angioplasty; and 2 underwent clipping of the aneurysm. There was 1 hospital death, in the case of a patient who sustained a postoperative myocardial infarction. Three patients had a postoperative neurologic deficit; this complication was permanent in 1 case and transient in 2. During long-term follow-up, no late stroke occurred; nevertheless, 3 patients died of a myocardial infarction, for an overall 5-year survival rate of 77%. On the basis of this study, we conclude that accessible aneurysms of the extracranial carotid artery can be excised with an acceptable morbidity and mortality.

Early experience with a new PTFE graft below the inguinal ligament.

Between July 1984 and July 1985, 65 expanded polytetrafluoroethylene grafts (Vitagraft) were implanted in the infrainguinal position in 51 patients, including 41 men and 10 women, with an average age of 63 years. The indications for surgery were severe claudication (36 grafts) or ischemic necrosis of the extremities (29 grafts). Thirteen of the patients (25%) had had a previously placed infrainguinal graft of another type that had failed, requiring reoperation. Proximal vascular reconstruction (consisting of ten aorto-femoral and two femoro-femoral bypasses) was performed in 12 patients who had 16 grafts. Simultaneous aortocoronary bypass surgery was done in conjunction with a femoral-popliteal bypass in six patients. The site of distal anastomosis was the suprageniculate popliteal artery in 21 grafts (32%), the infrageniculate popliteal artery in 33 grafts (51%), tibio-peroneal trunk in seven grafts (11%), and the posterior tibial artery in four grafts (6%). The mean follow-up was 9.6 months (range, 1 to 16 months). Two grafts (3.0%) failed early (< 30 days). Another three grafts (4.6%) occluded between 1 and 6 months postoperatively, and five occluded after 6 months. The cumulative patency rate at 15 months was 78.8%. Limb salvage was not possible in three patients, who underwent amputation because of multiple previous operations and a lack of distal run-off. There were no operative deaths, graft infections, aneurysms, or untoward reactions (including seromas) along the graft tracts. At this early follow-up date, we have not encountered the complications normally associated with other grafts; our early results indicate that continued clinical use is warranted.

The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft.

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.

Durability and low thrombogenicity of the St. Jude Medical valve at 5-year follow-up.

Between November, 1978, and December, 1983, 736 patients had valve replacement with the St. Jude Medical valve prosthesis. There were 478 patients with aortic valve replacement (AVR), 188 with mitral valve replacement (MVR), 63 with double valve replacement, and 7 with tricuspid valve replacement (they were not included in this study). The mean age at the time of operation was 46.7 years for patients having AVR and 48.6 years for those having MVR and AVR + MVR. Follow-up totaled 1,116 patient-years (range, 4 to 82 months). Early (30-day) mortality was lowest for isolated MVR (2.3%) and AVR (3.7%), and increased with reoperation or when associated procedures were combined with valve replacement. Patients undergoing reoperation or having associated procedures made up 49% of the AVR and 54% of the MVR groups. All patients were advised of the need for long-term anticoagulation with warfarin sodium. Nine patients (7 with AVR, 1 with MVR, 1 with AVR + MVR) had suspected or confirmed episodes of systemic thromboembolism, a linearized incidence of 0.99% per patient-year for AVR, 0.36% per patient-year for MVR, and 0.98% per patient-year for AVR + MVR. Eight patients with AVR underwent reoperation for prosthetic valve endocarditis (5 of the 8 patients had endocarditis prior to initial valve replacement). There were no instances of structural valve failure. There were 37 late deaths. Actuarial survival at 5 years (excluding early mortality, 95% confidence limits) was 89.8% for AVR, 84.8% for MVR, and 95.2% for AVR + MVR.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and late results of coronary endarterectomy. Analysis of 3,369 patients.

The effectiveness of coronary revascularization has been questioned in patients with diffuse coronary disease. Over a 14 year period (1970 to 1984), 30,464 patients underwent surgical revascularization at our institution. Coronary artery bypass alone was done in 27,095 patients and was combined with coronary endarterectomy in 3,369 patients (12.4%). Analysis of preoperative variables revealed an increased incidence of male sex, diabetes mellitus, low ejection fraction (less than 30) and multiple vessel disease in patients requiring endarterectomy. The early results after revascularization indicated a small increase in surgical risk after endarterectomy. The 30 day mortality for bypass alone was 2.6% versus 4.4% for coronary endarterectomy (p less than 0.01). Multivariate analysis identified independent predictors of operative risk: ejection fraction less than 30%, reoperation, age, absence of hyperlipidemia, endarterectomy, and female sex. Early mortality was significantly increased by endarterectomy in the left anterior descending coronary artery (8.5%) compared to endarterectomy in arteries other than the left anterior descending (4.2%) (p less than 0.01). In a sample of 4,473 patients, myocardial complications were also found to be increased after coronary endarterectomy. The incidence of perioperative myocardial infarction in patients undergoing bypass alone was 2.6% versus 5.4% for patients undergoing bypass plus endarterectomy (p less than 0.01). Both fatal and nonfatal cardiac arrests increased (bypass alone, 1.7%; endarterectomy, 3.5%; p less than 0.01). This suggests the failure mode of unsuccessful endarterectomy. Early mortality after coronary endarterectomy decreased substantially from 1970-1976 (6.4%) to 1977-1984 (3.5%; p less than 0.01). Actuarial analysis at 5 years and longer has shown very little difference in the long-term survival rate (coronary bypass, 90%; coronary endarterectomy, 86%), freedom from angina (coronary artery bypass, 58%; coronary endarterectomy, 52%), and freedom from reoperation (coronary artery bypass, 97%; coronary endarterectomy, 98%). Despite the small increase in surgical risk, the early and late results support the selective application of coronary endarterectomy in patients with diffuse distal disease and demonstrate the beneficial long-term effects.

Reoperation for aortic coarctation: techniques, results, and indications for various approaches.

To define the safety and efficacy of operation for recurrent thoracic aortic coarctation, we reviewed the hospital records and subsequent courses of 53 patients who underwent such procedures over a 23-year period. Previous operations included end-to-end anastomosis, prosthetic patch or subclavian flap aortoplasty, and prosthetic interposition or bypass grafts, performed in patients ranging from 1 day to 44 years old. Several different reoperative procedures were used, including an ascending-descending aortic bypass graft in 4 patients who had had two previous repairs. There were no hospital or late deaths and only 3 relatively minor complications. Only 2 patients have hypertension requiring drug therapy at follow-up, which now averages 7 years. We conclude that operative management of severe, recurrent coarctation is both safe and effective, and that several techniques of reconstruction may have a place in such therapy.

False aneurysm of the ascending aorta from an expanded polytetrafluoroethylene (Gore-Tex) aortopulmonary shunt.

A false aneurysm of the ascending aorta developed in a 25-month-old male infant with tetralogy of Fallot because of an expanded polytetrafluoroethylene (PTFE) shunt that had been inserted between the ascending aorta and right pulmonary artery when the patient was 3 months of age. Surgical repair of tetralogy of Fallot with ligation of the PTFE graft was performed at 19 months of age. The false aneurysm at the site of the systemic anastomosis to the shunt was discovered 6 months later and was successfully repaired. Because of the potential for graft dehiscence secondary to growth, we recommend that PTFE shunts be removed completely or, at least, ligated and divided at the time of corrective surgical intervention.

Aortico-left ventricular tunnel with ventricular septal defect: two-dimensional/Doppler echocardiographic diagnosis.

Aortico-left ventricular tunnel is a rare congenital anomaly that presents as aortic regurgitation and congestive heart failure in childhood. Its association with a ventricular septal defect is even more rare. Because of the distortion of the normal anatomy around the aortic valve and the rarity of this combination of defects, the diagnosis of aortico-left ventricular tunnel with ventricular septal defect may be difficult. The two-dimensional and Doppler echocardiographic findings of aortico-left ventricular tunnel are described.

Valve failure with the Ionescu-Shiley bovine pericardial bioprosthesis: analysis of 2680 patients.

Early reports on the excellent hemodynamic function and low thromboembolic rates of the Ionescu-Shiley bovine pericardial bioprosthetic valve (BPV) encouraged us to use it as our choice for valve replacement in 2680 patients from 1978 through 1983. Analysis of these patients at 5-year follow-up (mean 21.6 months) demonstrated the following important trends. Despite anticoagulation therapy in 48%, thromboembolism occurred in 88 patients for a linearized rate of 1.87% emboli per patient-year and was not time-related. The highest incidence of thromboembolism was in mitral valve replacement (MVR) (2.76% per patient-year). The actuarial freedom from reoperation resulting from valve failure at 5 years was 82% in aortic valve replacement (AVR), 87.1% in MVR, and 92.6% in AVR/MVR. The most distressing causes for reoperation were valve calcification (33 patients, 0.68% per patient-year) and leaflet disruption (11 patients, 0.23% per patient-year). Valve calcification was related to age, small valve size, and AVR position and increased with time, especially at the 4- to 5-year intervals. In patients under 30 years of age, calcification occurred in 18.7% at a mean time of 40.8 months in AVR and in 8.2% at 44 months in MVR, for an overall rate of 11.6%. Over the age of 30 years, it occurred in 14 patients (0.6%) at a mean time of 44 months. Leaflet disruption was not related to age and occurred later in AVR (50 to 58 months) than MVR (1.5 to 61 months). Events increased with time (mean range 37 to 58 months). Because of calcification and leaflet disruption, valve failure causing reoperation has increased significantly at the 4- to 5-year intervals even when valve replacement in patients under 30 years of age is excluded. If this trend continues, the valve failure rate will be exceedingly high on further follow-up. Thus we have limited the use of the BPV to a selected group of patients in whom valve longevity is less important than effective orifice size, thromboembolic rate, and freedom from anticoagulation.

False iliac aneurysms.

Of 2,389 aortoiliac, femoral bypasses performed from 1971 to 1983 at our institution, 182 pseudoaneurysms were observed; of these, only 17 were false anastomotic iliac aneurysms (9.4%) among 13 patients. The mode of presentation varied from pain or swelling in the lower quadrant of the abdomen, or a combination of both, to acute rupture of the false aneurysm in the abdomen. The surgical management of patients with false aneurysms was the same for those with true aneurysms. Three patients died because of complications during the early postoperative period. Histologic studies secured during operation provided evidence supporting our belief that the main causes of false iliac aneurysms are primarily a weakened host arterial wall and secondarily the inadequacy of suture material used.