A practical and effective approach for the prevention of ischemia-reperfusion injury after acute myocardial infarction: pressure-regulated tepid blood reperfusion.

BACKGROUND: The prevention of perioperative ischemia-reperfusion injury is of critical importance, and this issue becomes more important in patients undergoing an early emergent revascularization procedure after an acute myocardial infarction. In this study, we sought to test the hypothesis that our simplified pressure-controlled initial reperfusion technique would be protective against ischemia-reperfusion injury in this subgroup of patients. METHODS: The data of 20 patients (group I) who underwent an emergent coronary artery bypass grafting procedure were analyzed and compared with the results of 37 patients (group II) underwent an innovative reperfusion technique. In group I patients, the operation was carried out using standard techniques. In group II, after the completion of all anastomoses, reperfusion was initiated before rewarming with a pressure of 20 to 25 mmHg and continued for a 2-minute period. Systemic blood pressure was then gradually increased to 40 mmHg and the aortic root was perfused at this pressure for another 2-minute period. Following the completion of the second low-pressure reperfusion period, cardiopulmonary bypass flow was regulated to preoperatively calculated values until systemic temperature reached 37 degrees C. RESULTS: Both groups showed significant differences in terms of cardiac output, arrhythmia rates, and biochemical parameters. Spontaneous sinus rhythm recurred more frequently in group II (P < .01, 86% versus 45%). Atrial fibrillation attacks were observed in 5 and 3 patients in groups I and II, respectively. All patients were medically converted to sinus rhythm with amiadarone and/or beta-blockers. Persistent electrocardiographic changes indicating postoperative myocardial infarction occurred in 5 patients in group I and in 1 patient in group II (P = .003). Postoperative enzyme levels were found to be lower in group II patients and the differences became statistically significant at the end of 24 hours. CONCLUSION: These results indicate that our controlled initial reperfusion technique is effective in the prevention of ischemia-reperfusion injury. We advocate the use of this innovative technique as an alternative to complex controlled aortic root reperfusion with the guidance of the early promising results of this study.

Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery?

OBJECTIVE: Despite the refinements in surgical techniques and postoperative care, elderly women still have a higher prevalence of postoperative morbidity. METHODS: The outcomes of 112 elderly women (>80 years) who underwent an elective CABG procedure were compared with those of males operated during the same time interval (n, 164). RESULTS: Median age of female and male patients were 82 and 83 years, respectively. Mean number of grafts did not differ significantly (3.7+/-0.8 vs 3.9+/-0.3, p=0.4) between groups. Overall early operative mortality rate was 8.6% (24 of 276 patients); 8.9% (10 of 112 patients) for female and 8.5% (14 of 164 patients) for male patients (p=0.1). Postoperative complications including prolonged ventilation time (13.4% in females vs 8.5% in male, p<0.01), atrial fibrillation (40% in females vs 33% in males, p=0.01), sternal reclosure (8% in females vs 4.2% in males, p=0.01), pneumonia (5.3% in females vs 3% in males, p=0.03), leg wound infection (11.7% in females vs 2.4% in males, p<0.001), renal dysfunction (10.7% in females vs 7.3% in young patients, p=0.02) have been found to be significantly higher in elderly women. Mean intensive care unit (3.2+/-1.1 days in females vs 1.6+/-0.4 in males, p=0.03), and hospital stays (13.6+/-2.1 days in females vs 9.1+/-1.2 in males, p=0.02) were also longer in female patients. Five-year survivals including all deaths for female and male patients were 57% and 62%, respectively. CONCLUSIONS: In elderly women, revascularization procedures can be done with acceptable mortality rates; but these patients are still associated with a higher prevalence of postoperative morbidity when compared with the male counterparts. Therefore, these patients have to be very carefully evaluated preoperatively and their postoperative care should be more comprehensive to reduce the incidence of postoperative complications.

Long-term results of the left anterior descending coronary artery reconstruction with left internal thoracic artery.

BACKGROUND: Recent refinements in percutaneous techniques have resulted in an increase in the numbers of patients with diffuse coronary artery disease who are referred to cardiac surgeons. Long-segmental reconstruction of the diffusely diseased left anterior descending (LAD) coronary artery with the left internal thoracic artery (LITA) has been shown to be beneficial for patients with diffuse coronary artery disease. In this retrospective study, we analyzed the long-term outcomes obtained with this technique. METHODS: Between April 1997 and February 2006, 3736 coronary artery bypass grafting (CABG) operations were performed by our team. Of these cases, 524 patients (14%) with the diffusely diseased LAD underwent a long-segmental reconstruction procedure with a LITA graft. RESULTS: The cohort consisted of 372 men (71%) and 152 women (29%), and the mean age was 56.5 +/- 8.2 years. The mean length of the arteriotomy incision was 4.5 +/- 1.2 cm (range, 2 to 10 cm). Postoperative mortality was 1.9%, and the myocardial infarction rate was 6.9%. At 3, 5, and 7 years, overall survival was 93.8% +/- 0.5%, 89.6% +/- 1.5%, and 85.5% +/- 2.6%, and actuarial freedom from angina recurrence was 94.5% +/- 1%, 88.5% +/- 2%, and 82.9% +/- 3%, respectively. Among survivors, interim angiographic evaluation was performed in 128 patients at a mean follow-up of 52.4 +/- 13.5 months, and the patency rate of the LITA-LAD anastomosis was 91.4%. CONCLUSIONS: Patients with diffuse LAD disease present a major challenge for cardiovascular surgeons. The long-term results of long-segmental LAD reconstruction are very encouraging, and this approach may be used safely in this subgroup of patients.