Dissociation between improvement in angina pectoris and myocardial perfusion after transmyocardial revascularization with an excimer laser.

Xenon chloride excimer laser transmyocardial revascularization significantly reduced angina in all patients and increased regional myocardial perfusion in most patients; however, there was no correlation between symptomatic improvement and flow improvement. Patients' symptomatic improvement preceded improved perfusion by several months.

Early experience of off-pump coronary artery bypass using Octopus Tissue Stabilizer.

OBJECTIVE: The Octopus Tissue Stabilizer stabilizes segments of the beating heart using a series of suction cups that do not damage myocardial tissue or compromise hemodynamics. This allows the heart to be positioned with the arterial target on a stable platform. In this study we present our early experience of off-pump coronary artery bypass using the Octopus Tissue Stabilizer. METHODS: Between October 1997 and June 1998, 50 patients underwent off-pump coronary artery bypass using the Octopus Tissue Stabilizer (7.5% of all coronary artery bypass cases; average age: 67.0 +/- 12.2). Preoperative ejection fraction was 15-70% (43.0 +/- 14.0%). Median sternotomy was used for all operations. RESULTS: The average number of grafts per patient was 2.5 +/- 0.9. The average operating time was 191 +/- 47 minutes. No patients returned to the operating room for postoperative bleeding or tamponade. Average intraoperative blood loss was 297 +/- 190 ml. No patient experienced perioperative myocardial infarction. There were five hospital deaths and one late death. All patients were free of angina at discharge. No patients returned with angina or required clinical restudy. CONCLUSIONS: Off-pump coronary artery bypass offers the surgeon another tool to apply for appropriate patients. The Octopus Tissue Stabilizer allows the surgeon access to all parts of coronary circulation, extending the range of off-pump coronary artery bypass procedures, when the anatomy is appropriate.

Influence of ejection fraction on hospital mortality, morbidity, and costs for CABG patients.

BACKGROUND: Preoperative ejection fraction (EF) has been shown to adversely affect postoperative hospital mortality and morbidity for patients undergoing isolated coronary artery bypass grafting. METHODS: To investigate influence of EF on isolated coronary artery bypass grafting outcomes (overall hospital mortality, hospital cardiac mortality, hospital morbidity, and hospital costs), data were reviewed from 1,354 consecutive patients who underwent isolated coronary artery bypass grafting between January 1, 1990, and April 30, 1992, at a single nonprofit hospital. Overall hospital mortality was 4.06% (cardiac, 2.36%). Hospital morbidity was 14.25% (including mortality). Hospital costs (not charges) averaged $16,673 per patient. To explore the impact of preoperative EF, EF was stratified into regular intervals. Each interval was then compared with regard to hospital mortality, morbidity, and average costs. A new statistical tool, discharge analysis, was developed to analyze the cost data. This was necessary because previous efforts at cost analysis have used tools inappropriate for real world cost data. RESULTS: The statistical analysis showed that patients with EF of 0.40 or greater had the best outcomes (lowest mortality, morbidity, and cost). Once the EF is 0.40 or greater the EF does not carry further predictive value. At EF less than 0.40, patients with EF less than 0.30 have a poorer outcome than patients with EF of 0.30 to 0.39. CONCLUSIONS: (1) Ejection fraction is a valid predictor of mortality, morbidity and resource utilization based on statistical analysis. (2) Patients can be broadly grouped as having EF greater than 0.40, less than 0.30, or from 0.30 to 0.39 with regard to clinical and cost outcomes. (3) Postoperative length of stay is not predicted by risk-adjusted EF. (4) A new tool, discharge analysis, is presented to facilitate cost analysis.

Probability of valve repair for pure mitral regurgitation.

The advantages of mitral valve repair are well established. Unfortunately, not all valves can be repaired. This presents a dilemma for the surgeon in terms of advising the patient as to the timing of operation and in decision making during operation. Patients requiring correction for pure mitral regurgitation are a heterogeneous group. By classifying the patients according to the cause of mitral regurgitation and the pathologic anatomy, we determined patterns of repair in our surgical practice for 100 consecutive patients with pure mitral regurgitation treated from January 1990 through June 1991. Patients with degenerative valve disease that spares the central portion of the anterior leaflet were likely to undergo valve repair (22/24), whereas those patients with involvement of the central portion of the anterior leaflet were likely to require replacement (15/17). This disparity may be related to the techniques of repair that were used and has spurred us to use other techniques when faced with this problem. Patients with ischemic mitral regurgitation caused by anulus dilatation were likely to undergo repair (15/17), whereas patients with ruptured papillary muscle usually underwent valve replacement (8/9). Operative mortality in this series was accurately predicted by the Parsonnet risk score. Combining knowledge of the expected operative risk and the likelihood of valve repair based on anatomic and pathologic considerations should allow the surgeon to better inform patients of their surgical options.

Pulsatile dysesthesia and an axillary artery pseudoaneurysm associated with a penetrating axillary artery injury.

A patient is presented in whom an uncommon subjective complaint of pulsatile dysesthesia (periodic dysesthesias following a radicular pattern and occurring simultaneously with the transmitted pulse) occurred following a gunshot wound to the axilla. The patient's symptoms were relieved by the surgical obliteration of a pseudoaneurysm of the axillary artery.

Endoscopic closure of bronchopleural fistulas using a tissue adhesive.

Bucrylate tissue adhesive has been found to be effective in achieving closure of surgically created bronchopleural fistulas in dogs. Success was obtained with both endoscopic and direct application. Clinical application of this method in one patient was successful [unpublished observations]. We believe that the speed, low risk, and cost-effectiveness of this approach justifies its further use in these difficult situations.