Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery.

BACKGROUND: The results of coronary endarterectomy (CE) performed in addition to coronary artery bypass grafting (CABG) have been controversial. We aimed to examine the impact of CE performed in addition to CABG when compared with CABG alone in our unit. METHODS: Patients who had CABG between January 1995 and December 2001 were included. They were divided into two groups, the CABG-only group and CABG and CE group. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, cerebrovascular accident, renal impairment, and early mortality. RESULTS: Of 5,782 patients who underwent CABG, 461 patients (8.6%) required CE in addition to CABG. There was a higher mortality and incidence of postoperative renal impairment in the group of patients who had CABG and CE, with no significant difference in other outcomes. However, the patients in the CABG and CE group had a higher incidence of male sex, previous myocardial infarctions, preoperative renal impairment, and poor left ventricular function, with longer cross-clamp and cardiopulmonary bypass times than in the CABG-only patients. Although female sex, renal impairment, nonelective surgery, impaired left ventricular function, and peripheral vascular disease were associated with increased mortality in all the patients, and use of statins and aspirin was associated with a reduction in mortality, CE was not a predictor of mortality. Furthermore, on propensity scores analysis, CE was not associated with increased mortality. CONCLUSIONS: Coronary endarterectomy when combined with CABG seemed to be associated with a higher mortality than isolated CABG in our study groups, but this is related to comorbidities of these patients rather than the CE.

The predictors and outcome of recidivism in cardiac ICUs.

OBJECTIVE: Reinstitution of step-up care (recidivism) following cardiac surgery may be associated with increased mortality. This has, however, not been widely reported. METHODS: We, therefore, studied 8113 consecutive patients who underwent coronary artery bypass grafting (CABG), valve replacement/repair or combined valve+CABG surgery between January 1996 and December 2003 to determine the reasons for readmission to the intensive care unit (ICU) and their outcomes in terms of length of stay in (i) the ICU (ii) hospital and (iii) the in-hospital mortality following recidivism. RESULTS: Of the 7717 patients discharged out of the ICU, 2.3% (182) of patients [mean age 70.4+/-8.35 years (range 30-90 years); 65.4% (119) males] required step-up care. Recidivism was 1.8% (101 of 5633) following coronary artery by-pass grafting (CABG) and 3.9% (81 of 2084) following valve replacement/repair+/-CABG (P<0.05). The mean interval from ICU discharge to ICU recidivism was 6.6+/-8.4 days (range 6h to 28 days). The principal reasons for recidivism were (i) respiratory failure requiring reintubation and ventilation in 54.9% (n=100) of patients (ii) cardiovascular instability (including that secondary to dysrhythmias) and heart failure in 23.1% (n=42) (iii) renal failure requiring haemofiltration in 6.6% (n=12) (iv) sepsis in 1.1% (n=2) (v) cardiac tamponade/bleeding requiring re-exploration in 7.7% (n=14) and (vi) gastro-intestinal complications requiring laparotomy in 6.0% (n=11) patients. Multivariate analysis showed that, during primary ICU stay, respiratory complications, low cardiac output state, dysrhythmias, renal failure requiring haemofiltration and re-exploration for bleeding were independent predictors of recidivism. Following recidivism (i) the mean length of stay in the ICU was 6.65+/-6.2 days (range 4h to 51 days), (ii) mean hospital stay was 19.2+/-17.3 days (10-60 days) and (iii) the 30-day in-hospital mortality was 32.4%. CONCLUSIONS: Patients are more likely to require recidivism following valve surgery+/-CABG than CABG alone. Whilst respiratory complications were the most common reasons for recidivism in our study, patients who required mechanical supports to maintain vital functions following surgery were most prone to recidivism. Hence, efforts should be made to treat cardio-respiratory problems early in this group of patients to reduce ICU recidivism.

Modified septal myectomy and repair of mitral valve apparatus for the treatment of hypertrophic cardiomyopathy.

A modified technique is described of septal myectomy using a resectoscope and mitral valve repair to relieve left ventricular outflow tract obstruction and correct mitral regurgitation in a young patient with hypertrophic cardiomyopathy. This modification offers better control over the extent of septal tissue excision and may reduce the incidence of iatrogenic ventricular septal defect. Using this procedure it was possible to correct systolic anterior motion of the anterior mitral leaflet while obviating the need to replace the mitral valve.

Preventive stent placement for renal artery stenosis prior to emergent coronary artery bypass grafting.

PURPOSE: To illustrate the benefits of treating severe renal artery stenosis in renally compromised patients prior to surgery for coronary artery disease. CASE REPORT: A 63-year-old woman with unstable angina, severe coronary artery disease, and long-term severe renal impairment with a single functioning kidney underwent renal stent placement for high-grade renal artery stenosis prior to coronary artery surgery. The procedure improved her serum creatinine from 528 micromol/L at baseline to 385 micromol/L, and she subsequently underwent coronary artery bypass grafting without deterioration in her renal function. At 1 year, the patient has a serum creatinine of 400 micromol/L, and there is no evidence of in-stent stenosis. CONCLUSIONS: Percutaneous renal angioplasty or stenting prior to coronary surgery in patients with concomitant renal and coronary artery disease may reduce perioperative renal deterioration in this specific group of patients.