Yoav Paz

Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function

BACKGROUND Conventional coronary artery bypass grafting using cardiopulmonary bypass carries relatively high mortality and morbidity for patients with left ventricular dysfunction. METHODS Seventy-five patients with ejection fraction less than or equal to 0.35 underwent primary coronary artery bypass grafting without cardiopulmonary bypass between December 1991 and December 1994. Thirty-two patients (43%) had congestive heart failure, 11 (15%) were referred for operation within the first 24 hours of evolving myocardial infarction, and 21 (28%) up to 1 week after acute myocardial infarction. Eighteen patients (24%), 6 of whom were in cardiogenic shock, underwent emergency operations. RESULTS Mean number of grafts/patient was 1.9 (range, 1 to 4), and internal mammary artery was used in 66 patients (85%). Only 17 patients (23%) received a graft to a circumflex marginal artery. Two patients (2.7%) died perioperatively, and 1 (1.3%) sustained stroke. At mean follow-up of 28 months, 13 patients had died, and angina had returned in 7 (10.5%). One- and four-year actuarial survival was 96% and 73%, respectively. CONCLUSIONS Coronary artery bypass grafting without cardiopulmonary bypass is a viable alternative to conventional coronary artery bypass grafting particularly for patients with extreme left ventricular dysfunction or those with coexisting risk factors, such as acute myocardial infarction and cardiogenic shock.

Predictors of early and overall outcome in coronary artery bypass without cardiopulmonary bypass.

OBJECTIVE Cardiopulmonary bypass in coronary artery bypass graft operations may adversely affect the outcome especially in high-risk patients. The purpose of this study is to evaluate results of coronary artery bypass performed without cardiopulmonary bypass, in a relatively high-risk cohort, and to identify predictors of unfavorable outcome. METHOD Three hundred and thirteen (313) patients, 246 (79%) of whom had high-risk conditions, who have a coronary anatomy suitable for coronary artery bypass surgery without cardiopulmonary bypass, underwent this procedure between December 1991 and July 1995. Mean number of grafts/patient was 1.8 (1-5), and only 71 patients (23%) received a graft to the circumflex coronary system. RESULTS Early unfavorable outcome events included operative mortality (12 patients, 3.8%), nonfatal perioperative myocardial infarction (eight patients, 2.6%), emergency reoperation (three patients, 0.9%), sternal infection (five patients, 1.6%), and nonfatal stroke (two patients, 0.6%). Multivariate analysis revealed angina pectoris class IV (odds ratio 5.4) and age > or = 70 years (odds ratio 5.0) as independent predictors of early mortality. Preoperative risk factors such as repeat coronary artery bypass grafting (50 patients, 16%), ejection fraction < or = 0.35 (85 patients, 27%), acute myocardial infarction (86 patients, 28%), cardiogenic shock (ten patients, 3.2%), chronic renal failure (25 patients, 8%), chronic obstructive pulmonary disease (20 patients, 6%), and peripheral vascular disease (51 patients, 16%) did not increase early mortality. During 33 months of follow-up (range 1-57 months), there were 42 deaths, at least 16 cardiac-related (one and four years actuarial survival of 90% and 76% respectively), and 39 patients (12.5%) in whom angina returned. Calcified aorta (odds ratio 2.6) and old myocardial infarction (odds ratio 1.8) were independent predictors of overall unfavorable events. CONCLUSIONS Coronary artery bypass grafting without cardiopulmonary bypass can be performed with relatively low operative mortality in certain high-risk subgroups of patients; however, an increased risk of graft occlusion is a potential disadvantage. This procedure should therefore be considered only for patients with suitable coronary anatomy, in whom cardiopulmonary bypass poses a high risk. Although the risk of stroke is relatively low, the procedure is still hazardous for patients aged 70 years and over.

Treatment of deep sternal wound infections post-open heart surgery by application of activated macrophage suspension

Postoperative sternal wound infection remains a significant complication and generally causes considerable morbidity and mortality. Macrophages play a major role in the process of wound healing. In order to evaluate the efficacy of local injection of activated macrophage suspensions into open infected sternal wound space, a retrospective case‐control study was conducted. Sixty‐six patients with deep sternal wound infection treated by activated macrophages (group 1) and 64 patients with deep sternal wound infection treated by sternal reconstruction surgery with various regional flaps (group 2), were matched for gender, age, and risk index. In up to 54 months of follow‐up of group 1, 60 patients (91%) achieved complete wound closure. Two (3%) late deaths occurred unrelated to the procedure. Mortality rate in group 2 was 29.7% (19/64). Duration of hospitalization was 22.6 days in group 1 vs. 56.2 days in group 2. Patients with deep sternal wound infection following open heart surgery that were treated by activated macrophages had significantly less mortality as well as significant reduction of hospitalization in comparison to the surgically treated group. These results illustrate the advantages of using a biologically based activated macrophage treatment.

Mild increase in coronary sinus pressure with coronary sinus reducer stent for treatment of refractory angina.

Mild increase in coronary sinus pressure with coronary sinus reducer stent for treatment of refractory angina

Coronary sinus intervention for the treatment of refractory angina pectoris

We read with great interest the article “Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization” by Dr Richard Kones.1