Robert J. Hall

Mortality in patients undergoing coronary artery bypass surgery after myocardial infarction.

Abstract Data on 1,700 patients who underwent coronary artery bypass surgery without additional cardiovascular procedures at the Texas Heart Institute were analyzed, relating the interval between myocardial infarction and operation to early mortality (within 30 days after operation). Patients who underwent coronary artery bypass surgery after a recent infarction (within 2 months before operation) had a higher rate of early mortality (14.5 percent) than patients who had an old infarction (6.9 percent) or no previous infarction (4.1 percent). The interval between recent infarction and operation was most significant. Mortality in patients who underwent operation within the first 7 days after acute infarction (38.1 percent) was more than six times greater than in patients who were operated on 31 to 60 days after infarction (5.8 percent). Mortality of those operated on 8 to 30 days after infarction was 16.4 percent. Elective coronary artery bypass surgery after recent infarction is best accomplished after the first 30 days, when there is no increased risk to the patient. Emergency coronary artery bypass after complicated acute myocardial infarction may be a lifesaving procedure, but it is associated with increased early mortality and should be reserved for those whose condition has not responded to aggressive medical therapy.

Coronary Artery Bypass

Aortocoronary saphenous vein bypass (CAB) has become the preferred technique for myocardial revascularization in patients with ischemic heart disease (1–4). Evaluation of the results of CAB is essential for comparison with the accumulated knowledge of the natural course of coronary heart disease and for improvement of patient selection.

Collateral circulation in coronary artery disease

The coronary arteriograms and left ventriculograms of 202 consecutive patients were reviewed. All had at least 75% diameter reduction of 1 or more major coronary arteries. In 127 patients (63%), at least 1 major branch was totally occluded. Collateral circulation was seen in 125 of these 127 patients (190 of 192 totally occluded arteries). Of the 75 patients without total occlusion, only 2 with 99% (or near-total) occlusion had demonstrable collateral circulation (2 of 208 arteries). In no patient with 75 to 98% diameter narrowing was collateral circulation demonstrated (0 of 164 arteries). An analysis was made of the relation between left ventricular (LV) segmental wall motion and the quality of collateral circulation in 190 totally occluded arteries among 125 patients. Of 126 arteries with good collateral circulation, LV contraction was normal in 21%, hypokinetic in 48% and akinetic/dyskinetic in 29%. Of 64 arteries with poor collateral circulation, LV contraction was normal in 23%, hypokinetic in 55% and akinetic/dyskinetic in 20%. There was no statistically significant difference between the effect of good or poor collateral circulation on LV function. These data indicate that collateral circulation cannot be seen angiographically unless there is total or near-total occlusion, and that the presence of collateral circulation does not correlate with LV wall motion abnormalities, i.e., akinetic area, despite good collateral flow or normal wall motion despite absent or poor collateral flow.

Coronary revascularization in the elderly patient.

A total of 1,275 elderly patients (70 years and older) underwent coronary artery bypass alone from 1970 to 1981. The percent of elderly patients who underwent coronary bypass surgery alone increased from 2.04% in 1971 to 8.2% in 1981. Most of the patients had severe, disabling or unstable angina pectoris. The overall early mortality rate was 5.8%. The early mortality rate was 13.9% in the first group (1970 to 1975) of 158 patients compared with 4.7% in the second group (1976 to 1981) of 1,117 patients. An average of 3.1 bypass grafts per patient were implanted. On follow-up examination, angina was relieved or decreased in 89% of the patients. The 5 year survival rate was 80.6% and the 10 year survival rate was 44.1%, with an average attrition of 3.9 and 5.6%/year, respectively. It is concluded that elderly patients are high risk surgical candidates, yet the risk has decreased progressively because of improved techniques of medical and surgical management and myocardial preservation. This decreasing operative mortality rate provides evidence that when medical management of the elderly patient with severe angina fails, coronary artery bypass becomes a successful alternative.

Radiation-induced valvular dysfunction

Radiation-induced heart disease is a well described entity. Previous reports have concentrated on the effects of radiation on the pericardium and myocardium causing pericarditis and myocardial fibrosis. In the last decade, some investigators have described valvular thickening, fibrosis and regurgitation. This report presents experience with two patients with aortic valvular stenosis of hemodynamic significance, possibly caused by mediastinal radiation.

Aortocoronary saphenous vein bypass. Results in 1,492 patients, with particular reference to patients with complicating features.

Abstract During a 33-month period ending June, 1972, 1,492 patients underwent aortocoronary saphenous vein bypass (ACB). The early mortality with ACB alone was 7.1%, while mortality was more than double (14 of 86 patients died) when ACB was combined with resection or plication of a ventricular aneurysm. Twenty of 84 patients died in the early period following combined ACB and valve resection. One patient among 8 who had concomitant resection of an ascending aortic aneurysm died after operation. Factors that increased mortality in this series were advanced age, female sex, high coronary artery scores, left main coronary artery lesions, high left ventricular end-diastolic pressure, left ventricular dysfunction, congestive heart failure, the requirement for endarterectomy to perform the anastomosis, and recent acute myocardial infarction. Actuarial data from patients who underwent ACB without concomitant procedures show an annual attrition rate of 2.7% per year, which compares to rates of 4, 6, and 10% for patients with single, double, and triple coronary disease treated without operation. In 311 men and women under the age of 70 who had a coronary artery score below 13 and none of the other risk factors, the early mortality was 1.6% (5 patients) and the late mortality was 1.0% (3 patients).

Right aortic arch with an aberrant retroesophageal innominate artery: angiographic diagnosis.

A retroesophageal innominate artery is a rare congenital anomaly theoretically occurring if there is a break in either aortic arch proximal to the origin of the common carotid artery. The resulting vessel is the last off the arch and gives origin to a subclavian and common carotid artery (Fig. 1). In reality a persistent dorsal aortic root (5), this vessel may then be considered an innominate artery. The purpose of this paper is to report an angiographically documented, right aortic arch with retroesophageal left innominate artery and to indicate an error that has been made in the diagnosis of this anomaly. S. G., a 19-year-old white male, was referred for evaluation because of a heart murmur and dyspnea on strenuous exertion. His past history was interesting in that he had been hospitalized for four and a half months during the first year of his life with a diagnosis of “mucoviscidosis and aspiration pneumonia.” There had been difficulty with feedings associated with intermittent periods of cough, cyanos...

Auscultatory and echocardiographic features of mobile left atrial thrombus

Free floating ball thrombus of the heart is a rare disorder that usually involves the left atrium, particularly in association with mitral stenosis and atrial fibrillation. The diagnosis of ball thrombus is suspected clinically when there are auscultatory changes in the intensity of the murmur of mitral stenosis. Two-dimensional echocardiography is especially useful in the diagnosis of this condition. By combining phonocardiographic recordings with both M-mode and two-dimensional echocardiography, attenuation and disappearance of the murmur were demonstrated as the mobile thrombus randomly drifted into the mitral valve orifice. Reappearance of the cardiac murmur was noted as the thrombus was expelled from the orifice. This study, combining simultaneous phonocardiography and two-dimensional echocardiography, identifies for the first time the relation between thrombus movement into the mitral aperture and changes of the murmur of mitral stenosis.

Is postextrasystolic potentiation dependent on Starling's law? Biplane angiographic studies in normal subjects.

The cineangiograms of 26 normal subjects were analyzed to study the effect of Starlings mechanism on postextrasystolic potentiation. The end-diastolic volumes (single plane and biplane) of the left ventricle were similar in the regular sinus beat before an extrasystole and sequential sinus beats after an extrasystole. However, the ejection fraction, mean normalized systolic ejection rate, mean velocity of fiber shortening and long-axis shortening were consistently larger in the first sinus beat after an extrasystole. We conclude that postextrasystolic potentiation is independent of left ventricular end-diastolic volume in normal human hearts and the compensatory pause after an extrasystole does not result in increased end-diastolic volume.

Does Coronary Bypass Surgery Prolong Life Expectancy

While relief of disabling angina following coronary artery bypass (CAB) generally has been accepted, the influence of CAB upon long- term survival has remained controversial. Comparison of survival data of nonrandomized surgical series with “noncurrent” historic medxadical controls [1] has been criticized frequently, most recently by Braunwald [2], In addition, the results of two recent multicenter coxadoperative studies of patients with unstable angina (NHLI)[3] and staxadble angina (VAH)[4], who were randomly assigned to medical or surgixadcal therapy, show no difference in long-term survival.