Outcomes of Coronary Artery By-Pass Grafting Under Dual Antiplatelet Therapy in ST Elevated Myocardial Infarction.

Patients with recent myocardial infarction (MI) or percutaneous coronary interventions (PCI) have a higher ischemic risk in addition to perioperative bleeding risk when undergoing coronary artery bypass grafting (CABG). Data regarding preoperative dual antiplatelet therapy (DAPT) failed to create a clear recommendation. In the present study, we assessed the relationship between preoperative DAPT use and adverse outcomes, particularly in ST-elevation MI (STEMI) patients. We retrospectively analyzed 748 consecutive patients with STEMI who underwent subsequent CABG surgery. Patients were divided into 2 groups: those on DAPT up to the day before CABG and those discontinued DAPT >5 days before CABG. Predictors of in-hospital mortality and major bleeding were analyzed by multivariate analysis. Preoperative DAPT was not associated with in-hospital mortality (Odds Ratio (OR):1.81; 95% Confidence Interval (CI): .89-3.68, P = .10) and major bleeding (OR: 1.15; 95% CI: .63-2.08, P = .65) after multivariate analysis. However, glycoprotein (Gp) 2b/3a inhibitors were independently associated with higher major bleeding rates. Age, shock, and EF (ejection fraction) <30% were associated with in-hospital mortality. Previous MI, Gp 2b/3a inhibitors, and EF <30% were predictors of major bleeding. In conclusion, there were no association between pre-CABG DAPT use and in-hospital mortality and major bleeding.

Asymmetric dimethylarginine levels in Buerger's disease.

BACKGROUND: Endothelial dysfunction may play a major role in both peripheral arterial disease (PAD) and Buerger's disease (BD). Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase and increased ADMA levels impair vascular homeostasis. We aimed to determine the plasma levels of ADMA and evaluate the relationship of ADMA levels with smoking and clinical severity of the disease in patients with BD and to compare these results with those of patients with PAD and healthy individuals. METHODS: In our center, 45 patients undergoing peripheral arterial surgery, 28 patients being followed up for BD, and 24 healthy individuals without vascular or cardiac disease, were enrolled in the study. Intra- and intergroup analysis was performed to evaluate the relationship of ADMA levels with smoking behaviors and clinical disease severity according to Fontaine classification. RESULTS: ADMA levels were 1.26 ± 0.76 mmol/L, 0.87 ± 0.27 mmol/L, and 1.07 ± 0.88 mmol/L in patients with PAD, in patients with BD, and in the control group, respectively. ADMA levels were significantly higher in patients with PAD than those in control patients (p = 0.003) and the levels observed in patients with BD were significantly lower than those in control patients (p = 0.001). Smokers with PAD had higher ADMA levels than smokers with BD (p = 0.03). ADMA levels were higher in patients with Fontaine stage III and IV disease than those with Fontaine stage II diseases, for patients with PAD as well as those with BD. CONCLUSION: The lower ADMA levels observed in patients with BD might be related to the degradation of ADMA by dimethylarginine dimethylaminohydrolase in response to ischemia and could act as a defensive mechanism during the acute or quiescent phases. In patients with BD experiencing severe clinical conditions or with a longer time course for the disease, higher ADMA levels may suggest a poor prognosis.

Comparison of minimally invasive direct coronary artery bypass and off-pump coronary artery bypass in single-vessel disease.

BACKGROUND: Off-pump coronary surgery is an established method of less invasive cardiac surgery. We compared our early results in patents with I-vessel disease who underwent surgery with full sternotomy with off-pump coronary artery bypass (OPCAB) or a left anterior minithoracotomy with minimally invasive direct coronary artery bypass grafting (MIDCAB) without cardiopulmonary bypass. METHODS: From July 2003 to June 2006, 54 patients with single-vessel disease of the left anterior descending artery who underwent surgery performed by the same surgical team were included in this prospective study. Of these patients, 27 underwent MIDCAB through an anterolateral minithoracotomy, and 27 had OPCAB through a full sternotomy. Patients were selected for the surgical groups on the basis of general condition, anatomical aspects, type of coronary lesions, comorbidities, and patient preferences. Demographic, operative, and postoperative data were collected prospectively. RESULTS: Demographic data, Canadian Cardiovascular Society Classification, and comorbidities were identical for both groups. There were no cases of operative mortality, early graft insufficiency, myocardial infarction, cerebrovascular accident, or conversion to cardiopulmonary bypass in either group. Durations of mechanical ventilation and total hospital stay were shorter in the MIDCAB group, 6.8+/-3.0 hours vs 8.3+/-1.6 hours and 4.5+/-0.7 days vs 5.2+/-1.4 days (P= .03 and P= .03), respectively. Atrial fibrillation was seen in 2 patients in each group; all were returned to sinus rhythm by medical therapy. CONCLUSION: Although MIDCAB grafting is a challenging technique, it may be safely performed on selected patients with low postoperative mortality and morbidity.

Atrial fibrillation after surgical revascularization: is there any difference between on-pump and off-pump?

OBJECTIVE: Postoperative atrial fibrillation (AF) is still frequent complication after cardiac surgery in spite of the improvements in the surgical procedures. There is still controversy whether or not, the absence of cardiopulmonary bypass results in a lower incidence of AF. METHODS: Six hundred and seventy patients that underwent revascularization by using in situ LIMA for single vessel disease were included in this retrospective study and the patients were divided in two groups. Group I included 328 patients who underwent complete revascularization with cardiopulmonary bypass and group II consisted of 342 patients who underwent complete revascularization without cardiopulmonary bypass. Then, the incidence and predictive perioperative factors of AF in two groups were determined and compared with each other. RESULTS: There were no significant differences between two groups with respect to the preoperative demographic characteristics of the patients. The incidence of postoperative AF was determined as 16.1% after on-pump and 14.6% after off-pump revascularization. Avoiding cardiopulmonary bypass did not decrease the incidence of postoperative AF. Sex, age over 65 years, prophylactic beta-blocker usage and left ventricular dysfunction were independent predictive factors in group I (r2=0.51; P<0.001). However, only age over 65 years and prophylactic beta-blocker usage were independent predictive factors in group II (r2=0.59; P<0.01). The rates of AF in both groups were decreased by using prophylactic beta-blocker usage (P=0.05 in group I, P<0.001 in group II). CONCLUSIONS: There is no reduction of AF rate in myocardial revascularization without cardiopulmonary bypass. However, prophylactic beta-blocker usage decreases the incidence of AF after both on-pump and off-pump myocardial revascularization.

Effect of patient age at surgical intervention on long-term right ventricular performance in atrial septal defect.

Controversy exists about the influence of patient age on the benefit of surgery in atrial septal defect (ASD). Tissue Doppler echocardiography (TDE) when applied to atrioventricular annuli provides variables reliably reflecting the performance of the corresponding ventricle. We sought to investigate the effect of timing of surgery on biventricular functions by comparing the conventional echocardiography variables and TDE profiles of right and left atrioventricular annuli in patients treated at various ages. Conventional echocardiography and TDE analysis of mitral and tricuspid annuli were performed in 20 controls and 61 patients who underwent surgical ASD closure 2.8 +/- 2.5 years before the study. Standard parameters included were right and left-sided dimensions, estimated pulmonary artery pressure, ejection fraction, and tricuspid annular motion amplitude. TDE variables were systolic, early and late diastolic peak velocities at tricuspid lateral-and mitral-annulus at lateral and septal corners. Two subsets of patients who underwent surgery before (group 1, n = 20) and after 25 years (group 2, n = 41) formed our subgroups. Peak systolic TDE velocity and tricuspid annular motion amplitude had the lowest value in group 2 (P < 0.01 and <0.02, respectively). Late diastolic TDE velocity was significantly lower in group 2 compared to group 1 (P < 0.05). Increased right ventricular and atrial dimensions (P < 0.001 for both) and the estimated pulmonary artery pressure (P < 0.03) were the conventional measurements discriminating group 2 from group 1. The TDE profile of the mitral annulus was similar between the groups. These results suggest that delayed ASD closure is a relatively less effective procedure to restore secondary right ventricular dysfunction, as demonstrated by significantly different TDE measurements reflecting right ventricular longitudinal contraction and relaxation.

Daily comparison of respiratory functions between on-pump and off-pump patients undergoing CABG.

OBJECTIVE: Widespread application of on-pump revascularization procedures is increasing due to the thought of elimination of untoward effects of cardiopulmonary circuit. Thus, whether off-pump coronary artery surgery eliminates side effects especially related to respiratory functions is still controversial. Although many previous studies have evaluated these respiratory functions, daily comparison of 12 parameters was not included in any of the studies. The aim of our prospective study was to ascertain whether off-pump coronary operation improves pulmonary functions and postoperative recovery period when compared with on-pump technique and whether early discharge of patients with off-pump surgery is the result of respiratory improvement. METHODS: Eighteen patients in each group were included: on-pump group underwent coronary revascularization with cardiopulmonary bypass and off-pump with stabilization. Respiratory function tests and arterial blood gas analyses were performed preoperatively and daily after operation function tests included forced expiratory volume (FEV) in 1s, forced vital capacity (FVC), expiratory reserve volume, vital capacity, quotient of FEV in 1s to FVC, maximal voluntary ventilation (MVV), tidal volume, and forced midexpiratory flow. Blood gas analyses included partial arterial oxygen and carbon dioxide pressure, arterial pH and hematocrit (Hct). RESULTS: Preoperative pulmonary functions and arterial blood gases were not statistically significant between groups except MVV and partial arterial oxygen pressure. MVV was slightly higher in on-pump group and partial arterial oxygen pressure was slightly lower in on-pump group. During postoperative first day Hct (P=0.004) and FEV in 1s (P=0.049) values and third day partial arterial oxygen pressure (P=0.011) and Hct (P=0.011) values were lower in on-pump group. Mean extubation, duration in postoperative suit and hospital discharge times, mean blood loss were not statistically significant between groups postoperatively. CONCLUSION: Pulmonary functions and arterial blood gases were not improved in off-pump patients when compared with on-pump patients. Patients going to be surgically revascularized should not be altered to off-pump surgery merely with the hope of improving respiratory functions with off-pump technique. As the postoperative stay times at surgical theatre and hospital is not different and the extubation times were similar, early discharge of patients with off-pump surgery cannot be related merely to better preservation of respiratory functions.

Pacemaker related endocarditis: analysis of seven cases.

Vegetative electrode infection following permanent pacemaker implantation is a rare and serious complication. Among 1920 patients who underwent permanent pacemaker implantation in our institute between 1980 and 2000, 7 patients aged 65 to 78 years were diagnosed to have pacemaker related endocarditis. In this study, the clinical course and management strategies for these patients are reviewed. The most frequently encountered factors contributing to development of pacemaker infection were local complications such as postoperative hematoma and inflammation, and recurrent surgical interventions on the pacemaker system. In blood cultures S. aureus was the most common causative microorganism. Echocardiography could be performed in 5 patients. Three patients were referred to open-heart surgery for total removal of the pacemaker system, and one patient had his pacemaker system removed percutaneously. The remaining 3 patients did not agree to either surgical or percutaneous removal. These patients have been under antibiotic therapy for approximately 3 years and they still do not have any signs of a serious infection. Consequently, in patients with permanent pacemakers, infective endocarditis should be considered in the presence of fever and local symptoms. Blood cultures should be obtained and echocardiography should be performed. Complete removal of the pacemaker system with intensive antibiotic treatment is necessary for complete eradication of the infection. However, if percutaneous or surgical removal of the electrodes cannot be done because of high perioperative risk or the patient does not agree to undergo either method, medical treatment with long term antibiotic use may be considered as an alternative.