Lynn B. McGrath

CABG in octogenarians: Early and late events and actuarial survival in comparison with a matched population

BACKGROUNDnWith important demographic changes in cardiac surgical practice, more older patients are undergoing complex cardiac operations. Controversy exists as to whether the expenditure of healthcare resources on the growing elderly populations represents an effective approach in maintaining a meaningful quality of life.nnnMETHODSnFrom January 1982 through April 1991, 121 consecutive octogenarians underwent a surgical procedure that included coronary artery bypass grafting. Retrospective review of patient medical records was performed; follow-up information was obtained via telephone contact with the patient, the patients family, or the patients physician.nnnRESULTSnThere were 67 men (55%) and 54 women (45%). Mean age was 82.1 years (range, 80 to 89 years). Sixty-nine percent of the patients were having class III or IV symptoms. There were 11 hospital deaths (9.1%); risk factors included longer cardiopulmonary bypass time (p = 0.01), higher preoperative left ventricular end-diastolic pressure (p = 0.02), advanced age (p = 0.05), history of renal disease (p = 0.02), and myocardial infarction (p = 0.04). Late death occurred in 34 patients (30.9%) at a mean of 27 months postoperatively; univariate risk factors included chronic obstructive pulmonary disease (p = 0.009), higher left-ventricular end-diastolic pressure (p = 0.03), and recent myocardial infarction (p = 0.03). Actuarial survival, including hospital death, was 32.8% at 80 months, compared with 37.6% for an age; sex; and race-matched population (p > 0.3). Most late survivors (84%) were in New York Heart Association class I or II.nnnCONCLUSIONSnWe conclude that coronary artery bypass grafting can be performed in octogenarians with an acceptable, although increased risk. Hospital survivors have a good late functional status but are at risk for pulmonary and other atherosclerosis-related events, which impair overall survival.

Chronic type A aortic dissection: An unusual complication of cocaine inhalation

Acute aortic pathology temporally related to cocaine inhalation may lead to frank rupture or acute aortic dissection. This is a report of an unusual case of a 43-year-old man who presented 9 weeks after experiencing a tearing sensation in his chest while smoking cocaine. The diagnosis was chronic type A aortic dissection with 4+ aortic insufficiency. The successful surgical management included resuspension of the aortic valve and placement of a Dacron tube graft in the ascending aorta such that flow was maintained distally in both the true and false lumens.

Coronary artery bypass grafting after pneumonectomy

Coronary artery bypass grafting was carried out in a 61-year-old man 42 years after he had undergone right pneumonectomy. At the time of operation, the heart was displaced into the right hemithorax, which required modification of the operative techniques. Despite poor pulmonary function tests results preoperatively, the patient had an uneventful postoperative course. The success in this patient may be attributed to careful preoperative preparation, flexibility in the choice of techniques for establishment of cardiopulmonary bypass and coronary artery bypass grafting, and careful attention to perioperative fluid management.

Determining viability of fresh or cryopreserved homograft valves at implantation

SummaryStudies of homograft valves in the past two decades have suggested that “viable” valves, i.e., those maintaining chemical and structural integrity of their leaflet intercellular matrix, have a better long-term function than nonviable valves. The most effective qualitative methods of assessing leaflet viability involve destruction of the valve leaflets; thus, these methods have been limited to random use in selected valves. A study was conducted in swine in an attempt to establish a control tissue which could be tested in place of the homograft leaflets, thereby determining viability levels of every valve clinically implanted and correlating the results with long-term clinical function. Thirty samples each of the aortic and pulmonary artery wall and tricuspid leaflet were compared with aortic and pulmonary leaflets. Utilizing the technique of C14-proline uptake, viability was assessed at procurement, following sterilization, and following cryopreservation and short-term storage. The tricuspid leaflet was found to retain the same level of viability as the aortic and pulmonary leaflets before and after the cryopreservation period. It was concluded that the tricuspid leaflet could be utilized as the control tissue.

Management of an innominate artery aneurysm during an open heart operation

A 76-year-old woman was found to have a 4 x 2.5-cm saccular aneurysm at the origin of the innominate artery at the time of a reoperative open heart operation. The operative procedure was modified to include repair of the aneurysm with a Dacron patch. During the period of innominate artery occlusion, the patient was cooled to 25 degrees C and the mean arterial pressure was maintained at 90 mm Hg to maximize cerebral protection.

Antibiotic sterilisation in the preparation of homovital homograft valves: Is it necessary?

Homograft aortic heart valves collected at autopsy and treated with antibiotic solution before implantation have been found to be clinically superior to those sterilised by other methods (7, 9, 12, 20). Antibiotic sterilised aortic valves were first used clinically in 1968 at Green Lane Hospital. Since then, many antibiotic formulae have been devised.