Shigehiko Yoshida

Surgical management of unstable patients in the evolving phase of acute myocardial infarction

BACKGROUND Acute myocardial infarction (AMI) can be treated with thrombolysis or coronary catheter intervention; surgical treatment--coronary artery bypass grafting (CABG)--is reserved for the patients in whom other procedures have failed. We performed CABG in 47 patients during the evolving phase of AMI, and analyzed their short-term and long-term results. METHODS Preoperative, intraoperative, and postoperative data were analyzed in patients who underwent emergency CABGs for AMI between January 1, 1992, and July 31, 1998. CABGs performed more than 7 days after AMI were excluded from this study. RESULTS The subjects were 47 patients (33 males and 14 females) with AMI who were treated by emergency CABG. Intraaortic balloon pumping was used in 44 cases and percutaneous circulatory pulmonary support was used in 3 cases. The mean interval between the onset of AMI and surgery was 27.4 +/- 27.9 hours. The mean number of bypass grafts was 3.0 +/- 1.1, and at least 1 arterial conduit was used in 45 cases (95.7%). Aortic clamp time, pump time, and operative time were 64.7 +/- 31.7, 117.3 +/- 55.2, and 313.2 +/- 84.8 minutes, respectively. IABP or percutaneous cardiopulmonary support were removed in the intensive care unit (ICU) 30.0 +/- 28.9 hours after CABG. The patients were extubated 41.4 +/- 40.5 hours after surgery, remained in ICU for 4.7 +/- 2.7 days, and were discharged from the hospital after 27.0 +/- 22.5 days. Three patients died from multiorgan failure related to postoperative sepsis, and 8 cases of major complications were observed. The actuarial 5-year survival rate of the patients treated with CABG was 83.0%. CONCLUSIONS Surgical treatment in the unstable patients after AMI can be performed with acceptable risk. Arterial revascularization may contribute to improvement in long-term results.

Coronary artery bypass graft after esophagogastrectomy

A 71-year-old male with a history of retrosternal gastric bypass, after a resected esophageal carcinoma, developed angina pectoris due to stenosis of the left main trunk and the left anterior descending artery. The patient was treated with off-pump beating-heart coronary artery bypass approached via left thoracotomy. Two free conduits arising from the left internal mammary artery were utilized for this particular case, since the aortocoronary bypass was impossible due to the severely calcified aorta. Postoperative angiography confirmed good coronary flow and the patient has been symptom free for 6 months.

Coronary artery bypass grafting in patient with malignant neoplasm. Efficacy of coronary artery bypass grafting on beating heart.

OBJECTIVE Coronary artery bypass grafting (CABG) prior to noncardiac major surgery has effectively decreases short- and long-term mortality related to coronary ischemia. Coronary artery bypass on the beating heart is conducted to avoid the risk of cardiopulmonary bypass and it has contribute to shorten recovery time. METHODS Subjects were 19 patients with malignant neoplasm for whom a retrospective chart review was made between Jan. 1, 1992 and July 31, 1998. In the early phase of this study, between Jan. 1, 1992, and Dec. 31, 1997, CABG was performed using cardiopulmonary bypass, and late phase, between Jan. 1, 1998, and July 1, 1998, CABG was done on the beating heart without cardiopulmonary bypass. RESULTS Conventional CABG was performed in 12 patients with neoplasms (10 male and 2 female, age 64.7 +/- 6.1 years), and CABG on the beating heart was performed in 7 patients (6 male and 1 female, age 68.0 +/- 7.5 years). Fewer number of bypass grafts were made in the beating-heart CABG group (1.3 +/- 0.5 in beating-heart CABG versus 3.9 +/- 1.1 in conventional CABG). No cardiac events occurred in either group during the surgery for malignant tumors. The operative interval between CABG and cancer surgery was significantly shorter in the beating-heart CABG group (21.8 +/- 17.9 days in beating-heart CABG versus 53.5 +/- 42.9 days in conventional CABG, p < 0.05). CONCLUSION Patients with severe coronary artery disease and malignant neoplasms should undergo coronary artery revascularization before the neoplasm is treated. CABG on the beating-heart was safe and effective procedure in those with malignant neoplasms.

Revascularization using satellite vein after radial artery harvested for coronary artery bypass grafting.

The radial artery has been increasingly used for coronary artery bypass grafting and has excellent long-term patency rates. Hand claudication is one of the adverse effects after radial artery harvest. We reconstructed a radial artery using the satellite vein to prevent hand claudication. Pulsating blood flow at 35 cm/sec was evaluated using color Doppler echocardiography three months after surgery. This method makes it possible to use a radial artery in patients with a positive Allen test.