Gideon Merin

Comparison of Factors Associated With 30-Day Mortality After Coronary Artery Bypass Grafting in Patients With Versus Without Diabetes Mellitus

The purpose of this study was to identify factors associated with 30-day mortality after coronary artery bypass graft surgery (CABG) among diabetic patients, and to compare them with risk factors among nondiabetics. A subanalysis of a prospective national cohort study was performed which included patients who underwent CABG in 14 medical centers in Israel during 1994. Data including patient demographic and historical information, comorbidity, and cardiac catheterization results were collected by trained nurses. Data were derived from direct patient interviews, charts, catheterization reports, surgical reports, and national vital records. Multivariate logistic regression analysis was used to identify factors associated with a 30-day mortality in diabetic and nondiabetic patient populations. The results showed that crude mortality was 5.0% among diabetic patients (n = 1,034) and 2.5% among nondiabetics (n = 3,350; p < 0.001). The risk profile in diabetics was found to be worse. Multivariate logistic regression analysis identified female gender, 3-vessel disease, and left main disease as independent risk factors for 30-day, past-CABG mortality unique to diabetic patients. Left ventricular dysfunction was found to effect a greater risk among diabetic patients, whereas chronic renal failure was associated with greater risk among nondiabetics. In conclusion, we found differences in patterns of risk factors for post-CABG mortality between diabetics and nondiabetics. These findings may help physicians to identify patients at high risk for CABG mortality.

Using Cone and Plate(let) Analyzer to Predict Bleeding in Cardiac Surgery

The cone and plate(let) analyzer is an established method for assessing platelet function. It evaluates adherence of platelets on an extracellular matrix, expressed as a percentage of surface coverage and the average size of the aggregates. The purpose of this study was to determine the applicability of the cone and plate(let) analyzer in monitoring platelet function and predicting postoperative bleeding. The relationship between postoperative bleeding, perioperative platelet function, and other parameters was studied. A significant decrease in surface coverage was detected upon establishment of cardiopulmonary bypass (from 6.9% ± 3.9% to 4.7% ± 1.7%) with a return to preoperative values at the end of surgery. Preoperative average size and surface coverage were the only parameters that significantly and linearly correlated with postoperative bleeding. Patients with an aggregate average size < 20 μm2 had a significantly higher incidence of severe bleeding (> 965 mL) than those with a size > 20 μm2 (44% vs. 0%), and a higher mean blood loss (908 ± 322 mL vs. 337 ± 78 mL). Similar results were obtained for surface coverage < 5%, indicating the predictive value of these parameters. Preoperative platelet function as evaluated by the cone and plate(let) analyzer is an independent risk factor determining postoperative bleeding.

Double aortic arch associated with coarctation, ventricular septal defect and right ventricular outflow tract obstruction: Successful surgical repair

Abstract A case of complex congenital heart disease is presented with an unusual combination of extracardiac and intracardiac anomalies. Preoperative catheterization and angiographic studies demonstrated infundibular pulmonic stenosis, ventricular septal defect and coarctation of the aorta. A double aortic arch was subsequently detected during operation. Total repair necessitated staging of the surgical procedure. The coarctation was bypassed by interposing a synthetic graft between the anterior and posterior aortic arches. The second stage consisted of direct vision intracardiac correction of the pulmonic obstruction and the ventricular septal defect.

The Beneficial Effects of Chlorpromazine on Pulmonary Hemodynamics After Cardiopulmonary Bypass

Abstract The hemodynamic effects of chlorpromazine were studied in 12 patients 24 to 48 hours after open-heart operations. In the dose that was used (0.25 mg. per kilogram of body weight) the drug was found to have beneficial effects, particularly in patients with pulmonary vascular disease due to mitral valve dysfunction. The effects were manifested mainly by a significant decrease in pulmonary vascular resistance and a concomitant rise in cardiac output.

Incidental finding of myeloproliferative disorders during sternotomy.

We report 2 cases of myeloproliferative disorders discovered incidentally at the time of routine coronary bypass surgery. Suspicion of abnormal bone marrow tissue upon performing sternotomy and subsequent sampling for frozen section made the diagnosis. The surgical plan was changed, and partial revascularization without cardiopulmonary bypass was performed.

In situ implantation of a prosthetic systemic atrioventricular valve in corrected transposition

R E F E R E N C E S 1. Albanese SB, Carotti A, Di Donato RM, et al. Bidirectional cavopulmonary anastomosis in patients under two years of age. J Thorac Cardiovasc Surg 1992;104:904-9. 2. Hopkins RA, Armstrong BE, Serwer GA, et al. Physiologic rationale for a bidirectional cavopulmonary shunt. J Thorac Cardiovasc Surg 1985;90:191-8. 3. Jacobs ML, Rychik J, Rome JJ, et al. Early reduction of the volume work of the single ventricle: the hemi-Fontan operation. Ann Thorac Surg 1996;62:456-62. 4. Lamberti JJ, Spicer RL, Waldman JD, et al. The bidirectional cavopulmonary shunt. J Thorac Cardiovasc Surg 1990;100:22-30. 5. Jonas JA. Intermediate procedures after first stage Norwood operation facilitate subsequent repair. Ann Thorac Surg 1991;52:696-700.

Heat Acclimatization Protects the Left Ventricle from Increased Diastolic Chamber Stiffness Immediately after Coronary Artery Bypass Surgery: A Lesson from 30 Years of Studies on Heat Acclimation Mediated Cross Tolerance

During the period of 1986–1997 the first 4 publications on the mechanical and metabolic properties of heat acclimated rats heart were published. The outcome of these studies implied that heat acclimation, sedentary as well as combined with exercise training, confers long lasting protection against ischemic/reperfusion insult. These results promoted a clinical study on patients with coronary artery disease scheduled for elective coronary artery bypass operations aiming to elucidate whether exploitation of environmental stress can be translated into human benefits by improving physiological recovery. During the 1998 study, immediate-post operative chamber stiffness was assessed in patients acclimatized to heat and low intensity training in the desert (spring in the Dead Sea, 17–33°C) vs. patients in colder weather (spring in non-desert areas, 6–19°C) via echocardiogram acquisition simultaneous with left atrial pressure measurement during fast intravascular fluid bolus administration. We showed that patients undergoing “heat acclimatization combined with exercise training” were less susceptible to ischemic injury, therefore expressing less diastolic dysfunction after cardiopulmonary bypass compared to non-acclimatized patients. This was the first clinical translational study on cardiac patients, while exploiting environmental harsh conditions for human benefits. The original experimental data are described and discussed in view of the past as well as the present knowledge of the protective mechanisms induced by Heat Acclimation Mediated Cross-tolerance.

Preparation of Oxygenated Cold Crystalloid Cardioplegic Solution

The value of oxygenated, aqueous, cold cardioplegic solutions is being evaluated at several centers. The theoretical advantages of such a solution are counterbalanced in part by the complexity and expense of the preparation and delivery systems that have been used. A simple method is described that effectively achieves satisfactory levels of oxygenation of the cardioplegic solution within its original vinyl container.

Orthotopic Renal Autotransplantation in the Treatment of Renovascular Hypertension

Severe hypertension non-responsive to medical therapy was discovered in a 27-year-old woman in the third trimester of pregnancy. Renal arteriography after delivery revealed bilateral renal artery stenosis. The right kidney was smaller than the left one. The differential renal function studies, rather than the renal vein renin measurements, identified which side was causing the hypertension. An attempt at primary repair of the right renal artery failed. Orthotopic renal autotransplantation, using saphenous vein grafts that were interposed between the renal veins and the inferior vena cava, and between the segmental renal arteries and the abdominal aorta, reduced the blood pressure to normal values.