George M. Kroncke

Influence of increasing age on long-term survival after coronary artery bypass grafting

BACKGROUND Despite the steady increase in the number of elderly patients undergoing coronary artery bypass grafting (CABG), skepticism still exists as to whether this operation is justified in older people with a reduced life expectancy. The purpose of this study was to examine the effects of increasing age on outcome after CABG. METHODS A retrospective chart review was performed on 1,689 consecutive veterans of the United States Armed Forces undergoing isolated primary CABG from January 1972 through December 1994. For better comparison, they were arbitrarily divided by age into three groups: group I, 50 years of age or less (n = 213), group II, between 51 and 70 years of age (n = 1,258), and group III, more than 70 years of age (n = 218). Long-term survival for each group was compared to that of their age-matched population derived from Wisconsin life tables. RESULTS The preoperative ejection fraction was comparable in all three groups (p = 0.114). The patients older than 70 years of age had received more grafts per operation than the patients 50 years of age and younger (3.7 versus 3.3) (p = 0.0001). Although the aortic cross-clamp time was prolonged with advanced age (p = 0.0002), the cardiopulmonary perfusion time was shortest in elderly patients (p = 0.0001). The early (30-day) mortality for the entire study population was 1.3%. There was a linear correlation between increasing age and early (30-day) mortality: group I, 0.5% (1/213); group II, 1.0% (13/1,258); and group III, 3.2% (7/218). The overall 10-year actuarial survival for all patients was 67%. The 10-year survival was diminished with increasing age (p = 0.0001): 74% for group I, 68% for group II, and 47% for group III. Comparative analysis of the three groups with their age-matched counterparts demonstrated an age-related survival after CABG. In group I, reduced survival was evident 4 years after the CABG: the 10-year survival in group I was 74.2%, and the survival of their age-matched population was 93.4% (confidence interval, 67% to 81.9%). In group II a survival difference was obvious 8 years after CABG: 10-year survival of 67.5% versus 75.1% in their age-matched population (confidence interval, 64.8% to 71.6%). In the elderly group of patients, no survival difference was noted: 10-year survival of 42.7% versus 45.9% of the age-matched population (confidence interval, 29.8% to 64.6%). CONCLUSIONS An acceptable early mortality and long-term survival equal to those seen for an age-matched elderly population are sound outcome measures that support the justification of CABG in older patients irrespective of age.

Influence of age-specific lung function on survival after coronary bypass

BACKGROUND Respiratory complications after successful coronary artery bypass grafting influence the immediate recovery of a patient; however, whether they influence the longevity of a patient is largely unknown. The aim of this study was to examine the effects of preoperative pulmonary risk factors in younger patients and older patients on outcome after coronary artery bypass grafting. METHODS A retrospective chart review was performed on 939 patients who underwent primary coronary artery bypass grafting between July 1987 and November 1996. For better comparison, they were arbitrarily divided by age into two groups: group 1, less than 70 years old (n = 710), and group 2, 70 years old or older (n = 229). The variables collected for each patient included history of chronic obstructive pulmonary disease, active smoking, forced expiratory volume, and ventilatory support for more than 48 hours. These variables were compared with postoperative length of stay in the intensive care unit, length of stay in the hospital, and the midterm survival up to 5 years. The data were analyzed by the use of univariate/multivariate log-rank tests and the method of Kaplan-Meier survival estimates. RESULTS The presence of chronic obstructive pulmonary disease was associated with increased length of stay in the intensive care unit and in the hospital for both groups. Preoperative forced expiratory volume in 1 second, significantly affected length of stay in the hospital only in the patients less than 70 years old (p = 0.0001). Delayed extubation beyond 48 hours of ventilatory support resulted in prolonged length of stay in the intensive care unit and in the hospital for patients less than 70 years old (p = 0.0001, p = 0.0001, respectively) and patients 70 years old or older (p = 0.0001, p = 0.0001, respectively). The 5-year survival after coronary artery bypass grafting for both groups was significantly influenced by the level of preoperative forced expiratory volume in 1 second (p = 0.0004, p = 0.0282, respectively). CONCLUSIONS Patients with chronic obstructive pulmonary disease, irrespective of age, stay in the intensive care unit and in the hospital longer after coronary artery bypass grafting. In addition, preoperative forced expiratory volume in 1 second is a significant predictor of 5-year survival in the young and aged individuals undergoing coronary artery bypass grafting.

Is Milking and Stripping Chest Tubes Really Necessary

The purpose of this study was to determine if chest tubes that are not milked or stripped occlude more frequently than milked or stripped tubes, and if the amount of drainage varies according to the treatment of the tubes. Following coronary artery bypass graft procedures, 49 male subjects had their chest tubes milked every 2 hours, had them stripped every 2 hours, or served as controls (i.e., their tubes were neither milked nor stripped). An analysis of variance was applied to the results. There was no significant difference in total drainage volume, hourly zero drainage, heart rate, or occurrence of arrhythmias among the three groups of subjects. Four to 16 hours postoperatively, a significantly higher volume of drainage occurred in the subjects whose chest tubes had been stripped. Stripping is particularly discouraged during this interval. The chest tubes remained patent with or without milking or stripping. We conclude that neither milking nor stripping is necessary for the proper care of chest tubes. We recommend that tubes be positioned such that they promote continuous drainage.

Multiple calcified thrombi (rocks) in the right ventricle.

Large, organized right ventricular thrombi are rare. This report describes a 51 year old man with a history of recurrent pulmonary emboli treated with inferior vena cava ligation who subsequently developed multiple mobile calcified thrombi in the right ventricle. He was treated successfully by surgical resection. Unusual clinical presentation on admission consisted of a two component friction rub secondary to calcified masses rubbing against each other in systole and diastole. Cardiac catheterization showed a constrictive-restrictive pattern that persisted after surgery. The role of noninvasive studies in the diagnosis and long-term follow-up of the patient is emphasized.

Myocardial Revascularization of the Canine Circumflex Coronary Artery Using Retrograde Internal Mammary Artery Flow Without Cardiopulmonary Bypass

A new surgical technique using perfusion of the circumflex coronary artery with retrograde blood flow of the internal mammary artery (IMA) is described. This project was undertaken because the IMA is uniquely well supplied with blood: proximally through is attachment to the subclavian artery, along the sternum by the intercostal arteries to the aorta, and distally from the iliac artery by the epigastric and musculophrenic arteries. In this experimental study, the IMA in 16 dogs was ligated and divided at the subclavian artery, then dissected free down along the sternum to obtain sufficient length. The large subclavian end was then anastomosed to the circumflex coronary artery using a metal cannula technique to perfuse the circumflex bed while the anastomosis was being done. In all 16 dogs, the retrograde flow of the IMA was adequate to maintain the circumflex bed. It is postulated that this technique may have some limited use in man.

A Follow-up Study of Aortic Valve Homografts for Two to Four and One-Half Years

Abstract Fifty-two patients underwent replacement of the aortic valve with a homograft and were followed for two to four and one-half years. There was no intraoperative mortality; 3 patients died in the immediate postoperative period and 7 patients died after discharge from the hospital. The results are very favorable when compared with the results in patients who have undergone replacement with aortic valve prostheses and have been followed at least two years. Patients with aortic homografts have been spared the problems of anticoagulants, and no emboli have been recognized. Eighteen of 42 survivors now have diastolic murmurs that are not hemodynamically significant. Neither diastolic murmurs that have been present continually nor those that have appeared late have been associated with deterioration of the patients state, and all patients remain normally active with very few taking any medication. The homografts have proved to be excellent aortic valve replacements, and their continued use is justified.

Milk of calcium pericardial effusion : case report

A patient with milk of calcium (MOC) pericardial fluid secondary to radiation therapy is presented. We have been unable to identify a previous report of MOC pericardial fluid.

Use of the Ulnar Artery for Monitoring Arterial Blood Pressures and Blood Gases

A simple and effective technique is described for monitoring arterial pressures and blood gases using the ulnar artery at the wrist. This method can be used for up to five to seven days postoperatively and is admirably suited to adult patients. No permanent vascular or neurological damage to the hand has been observed in more than 300 patients in whom this method was used. A few patients have noted transient paresthesia following use of this technique. In 1 patient this persisted for three months postoperatively, but it is now resolving.