Andrew J. Franzone

The renin-angiotensin system is not responsible for hypertension following coronary artery bypass grafting

Systemic hypertension following coronary artery bypass graft (CABG) procedures has been reported to occur in 15% to 80% of cases. Previous reports have implicated the renin-angiotensin system as being responsible, at least in part, for this phenomenon. In this prospective study, 18 previously normotensive subjects were studied before, during, and after CABG. In 4 patients (22%), paroxysmal postoperative hypertension developed (systolic blood pressure greater than 150 mm Hg). There were no differences between the normotensive and hypertensive groups in plasma renin activity, angiotensin II level, or aldosterone level. Despite the trend toward elevation of these variables during cardiopulmonary bypass (CPB), all had returned to control levels within two hours after CPB, whether or not hypertension developed. Serum norepinephrine levels were elevated (.10 greater than p greater than .05) in the hypertensive group at the time hypertension developed. No other relationship or pattern could be defined to distinguish the hypertensive from the normotensive group. The renin-angiotensin system does not appear to be responsible for paroxysmal hypertension following CABG.

Manual Coronary Endarterectomy with Saphenous Bypass: Experience with 263 Patients

From January, 1972, until August, 1980, 271 manual coronary endarterectomies with bypass were performed in 263 patients. All patients underwent additional cardiac procedures simultaneously. The group contained 254 distal right and 17 left endarterectomies (including 8 double endarterectomies). Clinical follow-up was 100%, operative mortality was 2.3% (6 out of 263), and the rate of perioperative infarction was 4.9% (13 out of 263). Cineangiography was performed on 72 patients between 1 and 60 months after operation (mean, 15.4 months). Patency was 85% (61 out of 72). Endarterectomy in a dominant right coronary artery could be planned electively. Left coronary endarterectomy was performed only when diffuse disease prevented standard bypass. Coronary endarterectomy may be used to extend operability with excellent clinical results, low perioperative mortality, and high late patency. Careful attention to technical aspects of core removal and myocardial protection are necessary for consistent results.

Comparison of wire-guided percutaneous insertion and conventional surgical insertion of intra-aortic balloon pumps in 151 patients

Over a 25-month period, percutaneous wire-guided balloon catheter insertion was attempted in 51 patients, and intra-aortic balloon pump insertion was attempted by conventional surgical method in 100 patients. The success rate in the group undergoing percutaneous insertion was 90.2 percent (46 of 51) and 90 percent in the group undergoing surgical insertion (90 of 100). The indications for intra-aortic balloon counterpulsation were diverse in both groups. The major complication rate in the patient population undergoing percutaneous intra-aortic balloon pump insertion was 15.2 versus 15.6 percent for the surgical group, and there were no cases of leg amputation or aortic dissection in the percutaneous group; however, two cases of leg amputation and one case of aortic dissection resulting in death occurred in the surgical group. The percutaneous intra-aortic balloon pump insertion technique was successfully employed in conjunction with percutaneous transluminal coronary angioplasty in six cases. It is concluded that the wire-guided percutaneous balloon catheter method is a highly successful and rapid means of instituting intra-aortic balloon counterpulsation in a wide variety of clinical situations. However, because of the significant associated complication rate, the decision to institute balloon counterpulsation must weigh the benefit-to-risk ratio, and this procedure must still be evaluated on a case-by-case basis.

Transluminal coronary angioplasty during saphenous coronary bypass surgery: a preliminary report.

A previously described balloon tipped dilatation catheter has been used during revascularization surgery to dilate lesions which potentially could limit the runoff of the saphenous bypass grafts. A total of 34 lesions were dilated in 25 patients. Restudy of 12 patients (15 lesions) demonstrated positive results and no clinically significant complications. These preliminary results suggest an important role for transluminal coronary dilatation in the operative treatment of coronary artery disease.

Reduced incidence of intraoperative myocardial infarction during coronary bypass surgery with use of intracoronary shunt technique

Intraoperative myocardial infarction is a recognized complication of aortocoronary bypass surgery. One major cause of such infarction may be interruption of coronary blood flow, particularly in patient with poor coronary collateral circulation. In 30 patients use of an intracoronary shunt made it possible to limit the period of coronary occulusion during graft construction to a few minutes. Use of this shunt was associated with a reduced incidence of intraoperative myocardial infarction (as judged by the appearance of new Q waves) when these patients were compared with 50 patients operated on without this procedure (6 of 50 [12 percent] versus 0 of 30). The incidence of postoperative persistent S-T segment elevation was reduced from 21 of 50 (42 percent) to 5 of 30 (17 percent). Except for use of the shunt, the surgical technique was identical in the two groups of patients.

Adjunctive operative coronary artery balloon-catheter dilatation: Review of Lenox Hill experience

Operative transluminal coronary angioplasty (OTCA) has been used as an adjunct to coronary artery bypass surgery in 65 patients over a 56-month period beginning in May 1978. Experience has led us to use OTCA primarily in the left anterior descending coronary artery. The angioplasty catheter has undergone a number of modifications. Late restudy (8 to 56 months; mean, 24.1) data in 17 patients demonstrated that 15 of 19 angioplasty segments (78.9%) were patent.

Subxiphoid Pericardiotomy-Reply

In Reply.— The experience of Breyer and associates supports our impression that subxiphoid pericardiotomy is a procedure of choice for the treatment of acute cardiac tamponade. It is of particular note that these authors report one patient with a small right ventricular laceration from an attempted, but unsuccessful, pericardiocentesis. No complications from subxiphoid pericardiotomy occurred. The shorter drainage time reported by Breyer et al underscores the need to individualize removal of the catheter based on the quantity of daily drainage. We routinely remove the catheter when less than 30 mL of fluid has been drained during a 24-hour period. It is apparent from the data provided by Breyer et al that our population, which contained more uremic patients, experienced a much greater quantity of drainage fluid of from 300 to 3,400 mL (average, 1,133 ±192 mL). The longer drainage periods were not unexpectedly associated with the cases of highest fluid