Kemal Bayazit

Coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation: review of 2052 cases☆☆☆★

OBJECTIVE A total of 2052 patients operated on with the off-pump technique (coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation) between June 1993 and March 1996 are retrospectively reviewed. Predictors for early mortality, perioperative myocardial infarction, and low cardiac output state were statistically analyzed. METHOD Our indications for an off-pump procedure were either patients with technically suitable coronary lesions (the vast majority) or patients who could not tolerate cannulation, hypothermia, or cardiopulmonary bypass because of the poor left ventricular function (198 patients) and/or associated diseases or conditions (73 patients). RESULTS Overall operative mortality was 1.9% and perioperative myocardial infarction occurred in 59 patients (2.9%). According to logistic regression analysis, associated bronchial asthma (p = 0.0001), hypertension (p = 0.05), poor quality of the left anterior descending artery (p = 0.02), and ungrafted circumflex coronary artery disease (p = 0.007) were the early mortality predictors. Nonbypassed circumflex disease was also associated with a high incidence of perioperative myocardial infarction and low cardiac output state. No homologous blood or packed red cell transfusion was required in 74.2% of the patients. CONCLUSION On the basis of the presented data, off-pump coronary artery bypass grafting appeared to be a safe and effective technique in selected patients with appropriate coronary lesions.

Approach to sinus of Valsalva aneurysms: a review of 53 cases

OBJECTIVE The reported experience with sinus of Valsalva aneurysms (SVAs) is limited. Our approach to this subset of patients and an algorithm-dependent classification are presented. METHODS Between 1985 and 2000, 53 patients (mean age: 24+/-12; range 4--60) underwent repair for ruptured (64%) or non-ruptured (36%) SVA. Associated lesions were present in 21 patients; VSD in 18, moderate to severe aortic insufficiency in five, aortic stenosis in four (two subaortic membrane and one bicuspid valve), PDA in two, mitral insufficiency in one, tetralogy of Fallot in one and endocarditis in one. Operative procedures included simple or Teflon pledgetted direct suturing (31 cases; 58%), patch repair (21 cases; 40%), and stentless porcine bioprosthetic aortic root replacement in a case with extensive involvement and aortic root distortion (2%). Concomitant procedures were VSD repair in 18 patients, aortic valve replacement in four, aortic valve resuspension in three, subaortic membrane resection in two, PDA ligation in two, mitral annuloplasty in one and total correction in one. RESULTS Early mortality was 1.9%. A permanent pacemaker was inserted in one patient due to complete heart block. The survivors were followed up for 8.2+/-5 years (range: 21 days to 15 years). There were three reoperations due to suture dehiscence; patch repair was undertaken in these patients with no further unfavorable consequences. All patients were in NYHA Class I or II as of their last follow-up. CONCLUSIONS Repair of SVA can be performed with an acceptably low operative risk and a good symptom-free long-term outcome expectation. Echocardiography provides all the necessary details for diagnosis. Dual exposure/patch repair strategy is advocated in the ruptured cases.

Coronary artery bypass grafting in the awake patient: three years’ experience in 137 patients

OBJECTIVE Our experience with 137 patients operated on without general anesthesia is reviewed to explore the validity of our surgical strategy. METHODS Between October 1998 and January 2002, 137 patients underwent coronary artery bypass grafting with high thoracic epidural anesthesia. There were 47 female and 90 male patients, ranging in age from 37 to 92 years (mean, 68 +/- 12 years). Two patients underwent reoperation. Nineteen patients had contraindications for general anesthesia. Target vessels involved were the left anterior descending artery in 122, the right coronary artery in 6, the left anterior descending artery plus right coronary artery in 7, and the left anterior descending artery plus circumflex artery in 2 patients. Coronary artery bypass was performed through limited access in 74 patients (H-graft in 42 and rib cage lifting in 32 patients) and through a median sternotomy in 63 patients. Cardiopulmonary bypass was not used. RESULTS In 39 (28.4%) patients pneumothorax was observed during surgical intervention. There was no mortality. Of the 137 patients, 132 (96.3%) completed the procedure awake. In 58 patients the intensive care unit was not used. Eight patients were discharged from the hospital on the day of their operation. Mean length of hospitalization was 1 day (range, 0-3 days). One hundred thirty-one patients were followed up for a period of 3 months and 3 years after their operations, and 94.7% of the patients were symptom free. Control angiograms were obtained in 41 patients. Graft patency was 100%, with one radial artery graft spasm. CONCLUSIONS Our initial experience confirms the feasibility and safety of performing coronary artery bypass grafting in the conscious patient without general anesthesia. Further study is required to define the possible extent and limitations of this strategy.

Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions

UNLABELLED One hundred twenty patients who had diffuse atherosclerotic lesions necessitating reconstruction of the left anterior descending artery with or without open endarterectomy and coronary artery bypass grafting were investigated retrospectively and compared with 130 patients who underwent conventional bypass grafting in the same time frame. METHODS Sixty-one endarterectomies were performed with long arteriotomies (group I) and 59 patch reconstructions were placed over stenosing plaques without an endarterectomy (group II). Patients having only conventional coronary bypass constituted group III. RESULTS Hospital mortalities were 6.5%, 5.1%, and 1.5% in group I, group II, and group III, respectively (p = not significant). Five patients in group I (8.1%), six in group II (10.1%), and two in group III (1.5%) had perioperative myocardial infarction (group II vs group III, p = 0.016). Angiographic restudy of grafts to the left anterior descending system revealed a patency rate of 81.5% in group I, 79.1% in group II, and 94.4% in group III patients after mean periods of 6.3, 5.7, and 6.1 years, respectively (p = not significant). Actuarial survivals at 7 years were 94% +/- 5.0%, 74.8% +/- 16%, and 90.9% +/- 7.4% in groups I, II, and III, respectively (group I vs group II, p = 0.007; group II vs group III, p = 0.008). Freedom from recurrent angina at 7 years was 42.7% +/- 15.6% in group I, 33.5% +/- 19% in group II, and 71.9% +/- 14.2% in group III (group I vs group III, p = 0.03; group II vs group III, p = 0.0001). Thirty-four percent of patients in group I, 24% in group II, and 60.4% in group III were working actively in the late postoperative period (p = 0.0001). CONCLUSION Extended revascularizations of the left anterior descending coronary artery increase surgical risk, although not to a statistically significant degree, and should be performed only of necessity. However, once needed, revascularization is a lifesaving procedure with acceptable early and long-term results.

Left ventricular aneurysm repair: an assessment of surgical treatment modalities

OBJECTIVE Different closure techniques (linear vs. circular), as well as the efficacy of revascularization in the left ventricular aneurysm repair, with regard to immediate and mid-term results, were assessed and factors having influence on the early mortality and morbidity and survival were analyzed. METHOD Between January 1991 and November 1996, 248 patients underwent surgical repair for postischemic left ventricular aneurysm. A total of 26 of them were female (10.50%). Linear closure was employed in 121 patients (48.8 %) and circular (patch endoaneurysmorraphy) closure in 127 (51.2%). Coronary revascularization was added in 203 (81.9%) cases. Patients were followed for an average follow-up time of 39.3 months. RESULTS Early mortality rate was 6% (15 patients). The difference in mortality rate by the repair method was not statistically significant (8.3% in the linear closure group and 3.9% in the circular closure group, P = 0.15). Absence of preoperative angina pectoris (P = 0.029), dyspnea as the presenting symptom, a preoperative left ventricular segmental wall motion scoring of 14 or greater, a cardiopulmonary bypass duration exceeding 2 h (P = 0.004), an aortic clamping time exceeding 1 h (P = 0.026) were associated with early mortality. Concomitant coronary revascularization had no effect on early mortality. However, low cardiac output state was less frequent in patients with concomitant coronary revascularization (P = 0.022). Functional status improved in both groups. Follow-up extending to 81st month revealed no difference in survival between the groups (84% for linear closure group and 92% in circular closure group, including operative mortality, P = 0.12). However, functional status improvement was better in the patients who underwent circular repair (P = 0.0077). Revascularization appeared as having no important influence on both survival and functional status. A preoperative left ventricular segmental wall motion scoring of 14 or greater was associated with a higher incidence of early mortality, low cardiac output syndrome and poor long-term survival. CONCLUSION Left ventricular aneurysm repair is an important therapeutic intervention and can be performed with reliable results, regardless of repair method, either linear or circular. Long term results revealed better functional status in circular repair group. Concomitant coronary revascularization reduced the incidence of low cardiac output state. Performance of the unaffected regions of myocardium was found to be an important determinant of both early and late outcome.

Vascular complications related to percutaneous insertion of intraaortic balloon pumps

The hemodynamic effects of intraaortic balloon pumps (IABPs) are well known. The use of IABPs is prone to many complications, including those classified as vascular. These complications are said to be more frequent with percutaneous insertion techniques. These complications and the algorithm for identifying patients who are most likely to suffer vascular complications were evaluated in a retrospective manner in a group of patients that received percutaneous IABPs. The study group consisted of 449 patients. The mean age of these patients was 53.6 +/- 12.8 years (range, 18 to 80 years), and 24.7% were female. The early mortality rate of these patients was 53.2%. The mortality for patients in whom vascular complications developed was significantly higher than that in the patients who did not suffer any vascular complications (65.7% versus 50.8%; p = 0.018). Minor or major vascular complications developed in 17.4% (n = 78) of the patients. There was no statistical difference in the frequency of complications between the patients who received a sheathless IABP and those who received a sheathed IABP. Ischemic complications occurred in 16.6% of the patients who received a sheathless IABP and in 17.6% of the patients with sheathed IABPs (p < 0.05). Diabetic patients (relative risk, 2.5), female patients (relative risk, 1.83), patients with peripheral vascular disease (relative risk, 3.69), and patients undergoing coronary artery bypass operations (relative risk, 2.08) were at increased risk for suffering vascular complications. These risk factors should be evaluated before insertion of an IABP, and routes other than percutaneous femoral insertion are preferred if the patient is IABP dependent.

Routine coronary arteriography before abdominal aortic aneurysm repair

BACKGROUND As cardiac complications constitute the principal cause of early and late morbidity and mortality after the surgical treatment of abdominal aortic aneurysm (AAA), a prospective study was planned to evaluate the effects of revascularization of coronary arteries on survival after AAA repair during early and long-term follow-up periods. PATIENTS AND METHODS A total of 125 patients underwent elective repair of AAA between 1986 and 1994. Coronary arteriography was performed in all cases. All cases with critical left anterior descending artery (LAD) lesions underwent a coronary artery bypass operation either simultaneously or shortly before AAA repair. In addition, percutaneous transluminal coronary angioplasty (PTCA) was performed for symptomatic and critical stenosis of arteries other than the LADs, or if noncritical but symptomatic stenosis of the LADs existed. Early and late follow-up data were obtained for all cases, and late-term cumulative survival rates were calculated. RESULTS Coronary artery lesions were found in 66 (53%) cases. In 24 cases, AAA repairs were performed 2.3 (mean) months after coronary artery bypass grafting (CABG), whereas in 4 cases both procedures were performed simultaneously. PTCA was performed in 4 cases 3 to 4 days prior to the abdominal surgery. Even though the coronary artery lesions were found inoperable in 7 cases, these patients underwent repair of AAA because of rapidly expanding and painful aneurysms. Early mortality rate was 4% (5 cases), in which 3 of these were from the group inoperable for CABG. A mean follow-up of 3.17 years (3 to 87 months) was achieved for all discharged patients. Cumulative survival rates for 6 months and 1, 2, 3, and 6 years were 99%, 99%, 95%, 93%, and 89%, respectively. CONCLUSIONS The results of this study emphasize the importance of coronary artery revascularization for early, and especially for late, survival after AAA repair.

Carotid Disease in Patients Scheduled for Coronary Artery Bypass: Analysis of 678 Patients

The purpose of this article is to investigate the frequency of carotid disease and to identify high-risk groups among patients scheduled for isolated coronary artery bypass grafting (CABG) procedures under nonemergent conditions. A total of 678 consecutive patients underwent preoperative carotid artery duplex scanning (CADS) before CABG procedures. Morphology of carotid artery was determined and five groups were formed. Age, sex, cervical bruit, diabetes mellitus (DM), hypertension, smoking, history of cerebrovascular event (CVE), peripheral vascular disease (PVD), and severity of coronary artery disease were investigated to describe the high-risk group for carotid artery disease. In 41% of patients carotid examination produced normal findings; 46.2% had less than 60% luminal stenoses, 7.1% had 60-79% stenoses, 4.6% had 80-99% stenoses, and 1.2% had total occlusion. Previous cerebral ischemic events (CVE) (p < 0.05), hypertension (p < 0.01), smoking (p < 0.01), advanced age (p < 0.01), and female sex (p < 0.01) were identified as high-risk factors for carotid artery stenoses. There was a linear association between carotid disease and coronary disease (p < 0.05). Documentation of previous CVE, hypertension, smoking, advanced age, female sex, and severe coronary artery disease may be helpful in identifying patients at high risk for carotid artery stenoses.

Risk factors associated with development of atrial fibrillation early after coronary artery bypass grafting

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Warm blood cardioplegia: ultrastructural and hemodynamic study.

Forty patients with coronary artery disease were included in this study. Half of them received cold crystalloid and cold blood cardioplegia (group 1), and half received normothermic blood cardioplegia (group 2). In group 1, left ventricular stroke work index was 24 +/- 3 g.m/m2 1 hour after the operation, 29 +/- 8 g.m/m2 12 hours after the operation, and 33 +/- 6 g.m/m2 24 hours after the operation. In group 2, left ventricular stroke work index was 37 +/- 4 g.m/m2 1 hour after the operation, 37 +/- 4 g.m/m2 12 hours after the operation, and 44 +/- 7 g.m/m2 24 hours after the operation. Myocardial oxygen extraction 20 minutes after the termination of cardiopulmonary bypass was 0.28 +/- 0.03 in group 1 and 0.44 +/- 0.08 in group 2. Myocardial lactate extraction at the same time was -0.09 +/- 0.02 in patients receiving cold blood cardioplegia and 0.17 +/- 0.07 in patients receiving normothermic blood cardioplegia. Electron microscopic study revealed no calcium accumulation in the mitochondria in group 2 patients, whereas calcium accumulation was present in the other group.