Ellis L. Jones

Surgery for acquired heart disease The importance of completeness of revascularization during long-term follow-up after coronary artery operations☆☆☆★★★

Completeness of revascularization after coronary artery bypass operation has been shown to improve short- and medium-term outcome. The purpose of this study was to assess the independent contribution of completeness of revascularization to long-term outcome. A total of 2057 patients with multivessel disease with complete revascularization and 803 with incomplete revascularization, mean age 57 +/- 9 years, was studied. The patient groups were similar except for more prior myocardial infarctions, worse left ventricular function, and more three-vessel disease in the incomplete revascularization group. Complications of perioperative infarction and stroke were not different between those having complete versus incomplete revascularization. The hospital death rate for patients having complete revascularization during the period of study was 0.7% versus 1.5% for those having incomplete revascularization (p = 0.06). Length of hospital stay for the two groups of patients also was not different. At late follow-up (mean 11.7 years for complete and 10.8 years for incomplete) patients who had incomplete revascularization had a significantly higher prevalence of recurrent angina. Multivariate analysis demonstrated the strongest predictors of incomplete revascularization to be number of vessels diseased and left ventricular function (ejection fraction). The multivariate correlates of survival were older age, left ventricular dysfunction, and completeness of revascularization. Completeness of revascularization correlated with improved overall patient survival, as well as survival in patients with normal left ventricular function. Furthermore, the curves continued to separate over time, such that the difference was greater at 8 years than at 4 years, although by 12 years the curves started to converge.

Concomitant carotid and coronary artery reconstruction.

Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Kehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are: self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CE-CAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from, CAB alone.

Clinical, anatomic and functional descriptors influencing morbidity, survival and adequacy of revascularization following coronary bypass.

Clinical data on 3,479 consecutive patients having coronary bypass surgery were retrospectively analyzed. Perioperative complications, incomplete revascularization, and reduced long-term survival could frequently be correlated with manifestations of myocardial damage. Patients with triple vessel and left main coronary disease had a greater frequency of inotropic requirements than did patients with single or double vessel disease (7.9% and 8.6% vs. 3.8% and 4.2%). Inotropic requirements in the perioperative period were significantly increased for patients with preoperative left ventricular dysfunction; a history of heart failure or multiple infarctions did not significantly increase the incidence of inotropic requirements. Presence of previous myocardial infarction, heart failure, or left ventricular contraction abnormalities significantly decreased the ability to achieve complete revascularization with bypass grafting. Hospital mortality since 1976 has been 0.8% (25/3,040). Hospital mortality was significantly increased by history of myocardial infarction, hypertension, heart failure, extent of anatomic disease, presence of preoperative ST-T wave changes, and severe abnormalities of left ventricular function. Hospital mortality in patients with ejection fraction <0.35 was 3.4% vs. 1.3% for those >0.35. Anginal pattern, history of hypertension, previous myocardial infarction, preoperative heart failure all significantly affected long-term survival. Occurrence of perioperative myocardial infarction did not adversely influence long-term survival. Patients with normal left ventricular function had excellent 42 month survival regardless of vessel disease (95%, 96%, and 94% for single, double, and triple vessel disease, respectively). Survival was significantly less for such patients with abnormal left ventricular function. Inability to achieve complete revascularization did not adversely affect hospital mortality, but did significantly reduce late survival. The important effect which complete revascularization had on long-term survival appeared to increase with increasing severity of coronary disease. Although bypass grafting improves survival in patients with multivessel disease and left ventricular dysfunction, the benefits appear to be significantly reduced once manifestations of left ventricular damage have occurred.

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

Sternal Osteomyelitis and Mediastinitis after Open-Heart Operation: Pathogenesis and Prevention

Sternal osteomyelitis and mediastinitis caused by Pseudomonas cepacia developed in a patient undergoing coronary artery bypass two weeks after the operation. P. cepacia bacteremia from a contaminated pressure transducer had preceded and probably caused the chest infection. While other authors have suggested that postoperative sternal osteomyelitis and mediastinitis result from local wound contamination, this case suggests the importance of bacteremia as a cause of such gram-negative infections. Since patients undergoing open-heart operation are exposed to many sources of bacteremia, prevention of severe postoperative chest infections may depend in large part on careful preoperative evaluation of each patienc antibiotic regimens, and, as shown in this patient, on very thorough periodic review of equipment sterilization and intravascular monitoring practices.

Clinical, hemodynamic, and operative descriptors affecting outcome of aortic valve replacement in elderly versus young patients.

One hundred and fifty-two patients age 70 years or more underwent aortic valve replacement (AVR) at Emory University Hospital between July 1, 1974 and July 1, 1982. Of these, 98 had isolated AVR (elderly AVR group) and 54 had concomitant coronary artery bypass grafts (elderly AVR/CABG group). Results of surgery in these patients were compared to results in patients aged 20 to 69 years operated on in the same period (young AVR/CABG groups). Comparative descriptors with statistically significant differences included a higher incidence of both stable and unstable angina in patients undergoing concomitant CABGs ; less cardiomegaly in the young AVR/CABG group; less hypertension, a higher incidence of pure aortic regurgitation, and less frequent use of inotropes in the young AVR group; a higher perioperative stroke rate in elderly AVR/CABG patients; a higher perioperative psychosis rate in patients having CABGs regardless of age; and a longer postoperative hospital stay for the elderly patients. There were no significant differences between the four groups for the following descriptors: sex ratio; history of congestive heart failure; the presence of atrial fibrillation; left ventricular end diastolic pressure, ejection fraction and contractility; number of diseased coronary arteries; number of vessels bypassed; use of the intra-aortic balloon pump; re-exploration for hemorrhage; perioperative myocardial infarction rate; and major wound infection rate. Operative mortality was 5.1% for the elderly AVR group, 5.6% for the elderly AVR/CABG group, 1.9% for the young AVR group, and 5.1% for the young AVR/CABG group (p = NS). Overall, hospital mortality was 3.3%. Actuarial survival curves for all elderly versus all young patients showed no significant difference. The curve for elderly patients compares favorably with the actuarial survival of the same age group in the general population. Actuarial survival curves for the four subgroups did not differ significantly when compared at a follow-up of 36 months after surgery. We conclude that AVR with or without concomitant CABGs can be performed in elderly patients with an acceptably low mortality and morbidity, and the postoperative survival compared favorably both with younger patients and with the general population of the same age.

Influence of left ventricular aneurysm on survival following the coronary bypass operation.

Patients having coronary bypass and aneurysm resection (N = 40) or aneurysm plication (N = 32) were compared with patients having coronary bypass without aneurysm (N = 2782). Unlike other series, the primary indication for surgery in the aneurysm patients was angina pectoris, with heart failure playing a secondary role. Multivessel disease was present in 83% of the patients with aneurysm. Total occlusion of the anterior descending coronary artery was more prevalent in the group of patients who had aneurysmectomy (75%) than in the group of patients who had plication (38%), and more grafts/ patient could be performed in the plication group (2.6 vs 2.0). Location of the aneurysm was most often antcroapical (N = 55) and infrequently inferior (N = 6). Septal wall motion was akinetic or aneurysmal in 47% of the aneurysmectomy group, and 10% of the plication group. Postoperative requirements for inotropcs or intra-aortic balloon assist was much higher in the aneurysm group (aneurysmectomy or plication) than in patients without aneurysm having bypass. Hospital mortality for aneurysm patients was 2.7% versus 1.4% in patients without aneurysms having coronary bypass. The actuarial survival rate at 42 months for all aneurysm patients was 90%. Improvement in anginal symptoms after plication and coronary bypass (96%) was more frequent than with aneurysmectomy and coronary bypass (76%) and this was attributed to larger viable muscle mass and greater revascularization. Although two-thirds of patients having surgery for aneurysms had improvement in heart failure symptoms after operation, 30% of those having aneurysmcctomies and 35% of those having plications said they were unimproved after surgery. However, this could be explained by the finding that a significant number (35% of the aneurysmectomy and 45% of the plication group) were in heart failure Class I prior to operation. Hospital mortality has been progressively reduced and late survival increased by the surgical treatment of left ventricular aneurysm, primarily through early operation at a time when coronary bypass can be used as an adjunct to aneurysm resection or plication.

Influence of concomitant CABG and urgent/emergent status on mitral valve replacement surgery

BACKGROUNDnOutcomes and resource utilization of patients undergoing mitral valve replacement (MVR) with or without concomitant coronary artery bypass grafting (CABG) were reviewed.nnnMETHODSnData for 1,844 patients undergoing isolated primary MVR at Emory University Hospitals between 1980 and 1997 were recorded prospectively in a computerized database.nnnRESULTSnThe four groups included patients undergoing elective MVR with (n = 360) or without CABG (n = 1332) and urgent/emergent MVR with (n = 66) or without CABG (n = 86). Length of stay was significantly higher in patients undergoing elective MVR with CABG (15 days) than in those without CABG (11 days) but was not significantly different in patients undergoing urgent/emergent MVR with CABG (17 days) than in those without CABG (19 days). In-hospital mortality was significantly higher for patients undergoing elective (14%) or urgent/emergent (41%) MVR with CABG than in those undergoing MVR without CABG (elective:6%; urgent/emergent:20%). The 19-year survival rate was 32% for patients undergoing elective MVR with CABG compared with 51% for those without CABG and 28% for patients undergoing urgent/emergent MVR with CABG compared with 46% for those without CABG. Multivariate correlates of long-term mortality included older age, concomitant CABG, and urgent/emergent status. Hospital costs were significantly higher for patients undergoing elective MVR with (

What role should the intra-aortic balloon have in cardiac surgery.

33,216) than for those without (

Intraoperative angioplasty in the treatment of coronary artery disease

23,890) CABG. No significant difference in cost were noted between patients undergoing urgent/emergent MVR with (