Sandra Fraund

Early and medium-term results after on-pump and off-pump coronary artery surgery: a propensity score analysis

BACKGROUND Comparative publications on beating-heart off-pump coronary artery bypass grafting (OPCAB) surgery versus conventional coronary artery bypass grafting (CCAB) surgery frequently do not offer conclusive information because of investigator bias. METHODS Trying to eliminate this problem, a propensity score analysis of the data of all CCAB patients (n = 517) and OPCAB patients (n = 133) operated on by the same surgeons during the same time period (1998 to 2001) was applied. After matching patients with similar propensity score values, 97 CCAB patients and 72 OPCAB patients entered the final analysis. RESULTS Early results were similar in both groups: the 30-day mortality reached 1.4% in the CCAB group and 2.8% in the OPCAB group; strokes did not happen. Perioperative myocardial infarctions occurred in 4.1% of the CCAB patients and 4.3% of the OPCAB patients. Drainage blood loss in the first 24 hours after surgery (830 +/- 687 mL, CCAB group; and 909 +/- 678 mL, OPCAB group) was similar (p = 0.06) in both groups. Medium term results (freedom from percutaneous transluminal coronary angioplasty or reoperation, freedom from myocardial infarction, freedom from stroke, and the quality of life) also were not significantly different between the off-pump and on-pump groups after a mean follow-up of 27 +/- 11 months. CONCLUSIONS Our results suggest that elective-surgery patients with coronary artery disease can be operated on either on-pump or off-pump with the same early and late mortality and morbidity.

Coronary artery bypass surgery in diabetic patients.

Abstract  Background: Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes. This study examines the impact of diabetes on mortality and morbidity following coronary artery bypass surgery. Methods: We retrospectively analyzed 590 consecutive patients after coronary artery bypass grafting in 1998. Reoperations and combined procedures were excluded. A total of 137 diabetic (23.2%) and 453 nondiabetic patients were evaluated. Among the diabetics, 53 were treated with insulin and 84 were non‐insulin‐dependent. Diabetics suffered more frequently from hypertension, peripheral vascular disease, and more often had an increased body mass index (BMI). Results: There was no significant difference in mortality and major complications among insulin‐dependent diabetics, non‐insulin‐dependent diabetics, and nondiabetic patients. Diabetics suffered more often from superficial sternal wound infection and had a higher incidence of superficial wound infections at the vein harvest site. Conclusion: The present study suggests that diabetes increases the risk of superficial wound infections after coronary artery bypass grafting. But diabetics do not necessarily have an increased risk of major complications and mortality. (J Card Surg 2004;19:36‐40)

Rat cytomegalovirus and Listeria monocytogenes infection enhance chronic rejection after allogenic rat lung transplantation

The role of infection in the pathomechanism of obliterative bronchiolitis (OB) after human lung transplantation is controversial. In a rat lung transplantation model, we analyzed the effect of viral [rat cytomegalovirus (RCMV)] and bacterial infection [Listeria monocytogenes (LM)] on the development of chronic allograft rejection. Fisher rats underwent single left lung transplantation with allografts from Lewis rats. Postoperatively, animals were infected with either RCMV or LM, or served as noninfected controls. Animals were killed on day 120 and both lungs were evaluated histopathologically for chronic airway and chronic vascular rejection. Infection with RCMV produced a significant increase in the incidence of chronic airway rejection (66.7% vs. 20%), compared with noninfected long‐term surviving animals. In rats with bacterial infection (LM) a similar increase of chronic airway changes as in viral infection (50% vs. 20%) was observed. Chronic rejection of allografts infected with either RCMV or LM was associated with significantly enhanced expression of intercellular adhesion molecule‐1 (ICAM‐1) on the endothelium. More infiltrating leukocytes (CD18, CD11a, CD44) and ED1‐positive macrophages were found in allografts of infected animals. In this experimental model of chronic airway rejection in long‐term surviving rats, not only viral but also bacterial infection resulted in enhanced development of chronic airway and vascular rejection. These results support our hypothesis that infectious complications have a substantial influence on the development of OB in human lung allografts.

Immediate postoperative extubation after minimally invasive direct coronary artery surgery (MIDCAB)

We were interested whether immediate postoperative extubation and early discharge of the intensive care unit (ICU) is safe in minimally invasive direct coronary artery surgery (MIDCAB) patients. Therefore we retrospectively analyzed the data from 217 patients undergoing MIDCAB from 2/99 to 4/02. Immediate postoperative extubation was possible in 182/217 (83.9%) with eight patients needing reintubation (11.5+/-3.3 h). Ventilation time of the remaining 35 patients was less than 24 h in 31 patients (8.8+/-5.3). Sixty-nine patients (31.8%) were directly transferred from the ICU. Immediate extubation after MIDCAB surgery is safe resulting in an effective use of resources.

Antero-axillary access for hypoplastic aortic arch repair

A 16-year-old adolescent presented with systemic hypertension due to a hypoplasia of the aortic arch resulting in a significant stenosis. In childhood, he underwent surgery for aortic coarctation through a left posterolateral thoracotomy. We present the successful repair of the complete aortic arch that could be achieved applying a patch plasty of bovine pericardium through an anteroaxillary thoracotomy.

Should the Aortic Valve Be Replaced in Patients with Mild Aortic Stenosis Admitted for Coronary Surgery

BACKGROUND The question whether the aortic valve in patients with mild aortic stenosis undergoing coronary artery bypass grafting (CABG) should be replaced or left alone is still controversial. METHODS Between 01/1995 and 03/2004, 38 patients (30 male, 8 female, mean age 70.9 +/- 7.8 years) required redo AVR 7.1 +/- 4.8 years after primary CABG, while 202 patients (125 male, 77 female, mean age 72.7 +/- 7.8 years) underwent combined AVR and CABG (1.9 +/- 0.8 grafts/patient). To evaluate the different approaches, the data of the redo-AVR group were compared with the data of a propensity-score matched group of AVR + CABG patients. RESULTS All patients survived the procedure; the 30-day survival was 94.7 % in both groups. The 1- and 5-year survival rates were 94.7 % and 83.8 % in the AVR after CABG group, and 94.7 % and 86.9 % in the AVR + CABG group, respectively. The late mortality was 28.9 % in the AVR after CABG and 25 % in the AVR + CABG group. Statistically, significant differences regarding perioperative mortality and morbidity could not be detected, neither with nor without propensity score analysis. CONCLUSION Combined AVR and CABG in patients with coronary artery disease and mild to moderate aortic stenosis seems advisable in an institution with an equally low perioperative risk for both procedures, because the patient will need only one surgical procedure instead of undergoing surgery with all the associated risks twice.