A biodegradable patch used as a pericardial substitute after cardiac surgery: 6- and 24-month evaluation with CT.

Biodegradable patches made of polyhydroxybutyrate (PHB) were recently shown to limit postoperative pericardial adhesions when inserted into the pericardium in sheep. The present study was carried out to evaluate the presence of post-operative retrosternal adhesions after cardiac surgery in patients operated on with the PHB patch compared with those operated on without the insertion of such a patch. 50 patients admitted for CABG and/or valvular replacement were randomised to treatment either with pericardial closure with a patch or with the pericardium left open. In 39 of these (19 with and 20 without a PHB patch) computerised tomography was carried out six and twenty-four months postoperatively. Computerised tomography indicated a lower incidence (p < 0.05) of postoperative adhesions between the patch and the cardiac surface in the patch group, compared with the corresponding area in the non-patch group. A reduction of patch size in 27% (p = 0.003) was also seen.

Right internal mammary artery for myocardial revascularization: early results and indications.

The right internal mammary artery (RIMA) was used for coronary artery bypass grafting in 258 patients from October 1985 to October 1991. The RIMA was inserted as the only graft in 8 patients and in combination with the left internal mammary artery (LIMA) in 231 patients, the right gastroepiploic artery in 19, and autologous vein in 184. The patients received a total of 1 to 8 distal anastomoses (mean number, 3.3). A total of 64% of the RIMAs were anastomosed to the left anterior descending coronary artery. The primary indication for use of the RIMA was small-vessel disease in 86 patients, repeat bypass grafting in 32, varicose or stripped saphenous veins in 61, and "selected routine case" in 79. The early (< or = 30 days postoperatively) mortality rate in these four groups was 8.1%, 6.3%, 0%, and 0%, respectively (p < 0.01). Independent risk factors (logistic regression analysis) for early mortality were small-vessel disease, insufficient grafting, repeat coronary artery bypass grafting, diabetes, history of smoking, age of 60 years or older, and family history of ischemic heart disease. Combined into a risk index, these risk factors identified six risk groups with early mortality of 0% in the four low-risk groups and 5.6% and 58.3% in groups V and VI, respectively (p < 0.0001). No RIMA-related variables were risk factors for significant postoperative myocardial enzyme release. Intraoperative electromagnetic flow measurements revealed no differences between the RIMA and LIMA. Early angiographic patency in 50 patients was 98% for the RIMA and 93% for the LIMA.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiarterial coronary artery bypass grafting with special reference to small vessel disease and results in women.

From 1985 to 1991 a total of 220 patients underwent coronary artery bypass grafting (CABG) with at least two native pedicled artery grafts. Bilateral internal mammary artery (IMA) grafting was performed in 201 patients, IMA combined with gastro-epiploic artery (GEA) grafting in five, and double IMA plus GEA grafting in 14; in addition 156 patients received 1-3 vein grafts. The primary indication for elective multi-arterial CABG was coronary arteries of small calibre (small vessel disease) in 77 patients, repeat CABG in 17 (without small vessel disease), varicose/stripped saphenous veins in 57 (without small vessel disease), while the remaining 69 were routine cases; the distribution differed between women (42, 0, 47, and 11%, respectively) and men (33, 10, 19, and 38%, respectively; P < 0.0001). The women also were older (62 +/- 7 vs 56 +/- 9 years; P < 0.001), and had higher prevalences of systemic hypertension, diabetes mellitus, and hypercholesterolaemia. The number of artery grafts and total number of grafts were, however, similar for women and men. Early mortality (< or = 30 days) was 5.6% in women and 2.4% in men (ns). Early mortalities in relation to primary indications were: 7.8% for small vessel disease, 5.9% for repeat CABG, and 0% for both varicose/stripped saphenous veins and routine cases (P < 0.05). Logistic regression analysis identified small vessel disease, insufficient grafting, age of > = 60 years, a history of smoking, a family history of ischaemic heart disease, and female gender as independent risk factors for early mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for chronic left ventricular aneurysm. Benefits and side effects.

Seventy patients who underwent elective resection of symptomatic postinfarction apico-anterior left ventricular (LV) aneurysm with or without coronary revascularization are reviewed. The early (< or = 30 day) mortality was 5.7%. Mural thrombosis occurred in 29 cases (41.4%), unrelated to the degree of preoperative LV impairment and predictable from preoperative LV angiography in only seven cases. The response to surgery comprised significant overall improvement of global LV ejection fraction (LVEF) during rest and of all variables in stress testing. This LVEF recovery correlated significantly with that of peak ejections rate, a variable of myocardial contractility. Contrastingly, right ventricular ejection fraction (RVEF) at rest decreased slightly but significantly without correlation to preoperative RVEF or LVEF. In comparisons between patients with congestive heart failure or angina at rest as dominant symptom, the former group showed greater depression of preoperative watt and LVEF but better postoperative recovery of these variables, while right ventricular deterioration was significant only in the latter. Postoperative recovery was best in patients with poor preoperative LV function (LVEF < or = 20%), even when surgery comprised only aneurysmectomy in isolated but ungraftable LAD disease (5 cases). The observed RV deterioration may be 'nonspecific', but it must be kept in mind as a side effect of the operation, as it detracts unpredictably from postoperative ventricular recovery. Patients with well preserved preoperative LVEF, small LV aneurysm and marginal expected post-aneurysmectomy changes according to LaPlace's law are probably at risk, and surgery should then instead be directed towards preserving the remaining viable myocardium by direct revascularization.

A "new" intraabdominal artery. The pedicled right gastroepiploic artery for myocardial revascularization.

The right gastroepiploic artery (GEA) was used as a pedicled conduit for direct coronary artery revascularization in 20 patients presenting with more or less exhausted saphenous vein resources. The early angiographic patency of the GEA conduit appears to be satisfactory when it is connected to the right coronary artery system. A distinct disadvantage of GEA grafting is the necessity to enter the abdominal cavity, which may lead to probably rare and as yet unrecognized morbidity. Future abdominal surgery may injure the GEA conduit unless its topographic relations to the prepyloric antrum, liver and diaphragm are properly recognized. The surgeon must then be prepared to encounter antegastric, retrogastric, antehepatic, transhepatic and retrohepatic routes of the redirected intraabdominal artery. The present paper addresses this problem. Preoperative angiography of the celiac trunk and superior mesenteric artery may be helpful in decision-making when a patient reports or records show that a graft has been harvested from the abdominal cavity.

Myocardial revascularization with three native in situ arteries. Gastroepiploic and bilateral internal mammary artery grafting.

Three native arteries were used for coronary artery bypass grafting in six patients in whom complete revascularization was not feasible because of varices or previous venous stripping. The right gastroepiploic and both internal mammary arteries were placed as pedicled conduits, and four patients additionally received a total of six vein grafts available from the greater or lesser saphenous system. Surgical complications were minimal and complete relief from angina was obtained in all patients, even in maximal stress testing. All 24 grafts were angiographically checked: 23 (96%) were patent and one gastroepiploic artery was occluded. All patients had at least three patent grafts. These native arteries are excellent conduits when suitable veins are not available. They should also be used on individual indications to replace occluded grafts.

Bilateral internal mammary artery for coronary revascularization. Early experience of 100 cases.

One hundred cases are presented in which both right and left internal mammary artery (IMA) were used as coronary bypass grafts. Special indications were thrombosis of previous venous graft (14 cases), poor venous resources (10) and small-vessel (probe less than 1.5 mm) disease (34), but bilateral IMA was used also for routine revascularization (42 cases). The total 212 distal IMA anastomoses included 12 jump grafts, three free grafts and seven thrombendarterectomies. There were 3.8 distal anastomoses per patient, 2.1 with IMA and 1.7 with vein graft. The right IMA was preferably inserted into LAD and the left into diagonal or obtuse marginal coronary artery. Excessive postoperative bleeding was the only major complication attributable to bilateral IMA grafting in the 97 survivors of surgery. In routine revascularization the procedure involved minimal morbidity and no mortality. The superiority of the IMA as regards long-term patency is widely recognized. Since many thrombosed vein grafts will require replacement, we believe that bilateral IMA grafting will become common, and it is also an option when no suitable vein is available.