Selection of Patients for Coronary Artery Bypass Operations

Bypass operations have proved to be an effective treatment for advanced coronary artery disease. Randomized clinical trials have now shown that compared with medical treatment, bypass operations enhance survival in patients who have three-vessel disease or left main coronary stenosis. The goals of both medical and surgical treatment should be to improve a patient''s quality of life, extend survival and reduce medical care costs. Preliminary data suggest that bypass operations may be less costly than medical treatment in patients with severe angina that requires repeated or prolonged stays in hospital.     

Cardiac surgery in Wessex.

The results of 3000 consecutive operations using cardio-pulmonary bypass show that the overall early mortality was 6.1%, dropping from 8.9% in the first 1000 to 4.4% in the third 1000. Operations for valve disease have been the most common, the early mortality for aortic valve replacement being 3.1% and for mitral valve replacement 2.9%. Combined aortic and mitral valve replacement had an early mortality of 4.4%. The number of patients undergoing isolated coronary artery bypass grafting has increased from 59 in the first 1000 to 292 in the third 1000 operations, with an overall early mortality of 1.3%. Six hundred and ninety seven patients underwent surgery for congenital heart disease with an overall early mortality of 10.9% (7.5% in the last 2000 cases). The patients have been followed up from one to 8.5 years. A high proportion have returned to work and enjoy a normal life. At the time of review, 87% of the 3000 patients were alive. Long waiting times for outpatient and inpatient care indicate underprovision of facilities relative to regional demand.     

Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.     

NONCARDIAC SURGERY COMBINED WITH CORONARY ARTERY BYPASS

The coexistence of coronary artery disease with noncardiac disease often leads to a dilemma in planning therapeutic procedures. This problem is especially difficult in the presence of accelerated angina or left coronary artery stenosis. A series of 17 patients is presented in which coronary artery bypass grafts were combined with noncardiac operations without mortality or significant morbidity. An illustrative case report shows the interrelated nature of the coexisting disorders. The conclusion of this study is that, at times, various surgical procedures should be combined with coronary artery bypass grafting for a smoother, less complicated recovery. However, there are no hard and fast rules dictating combined procedures; each operation must be planned according to the existing conditions and needs of the individual patient.     

Combined surgical approach to carotid and coronary artery disease

The aim of this study was to compare two different surgical approaches to patients with coexistent significant carotid and coronary artery obstruction. Patients were treated with combined operation of carotid endarterectomy and coronary artery bypass grafting (CEA/CABG). The first group of patients underwent the CABG procedure with the cardiopulmonary bypass (CPB) on arrested heart and the second group without the CPB on a beating heart--off pump. Between May 15 1998, and October 9 2003, thirty-five consecutive patients underwent the combined procedure. In both groups there were no cases of transient or permanent perioperative neurological events. Overall, early mortality was 5.6%. The incidence of a perioperative myocardial infarction was 5.5%. In the follow-up period there were no cases of late stroke. According to the presented results in this study, it was found that the combined CEA and CABG is an equally safe and effective procedure performed with or without cardiopulmonary bypass for patients with a severe coexistent carotid and coronary artery disease.     

Giant aneurysm of an aortocoronary venous bypass graft compressing the right ventricle

A 69-year-old man with a history of coronary artery bypass grafting and a recent inferoposterior myocardial infarction presented to the hospital for diagnostic coronary angiography. Physical examination, laboratory analyses, coronary angiography, echocardiography, and CT scan were performed. A giant aneurysm of the aortocoronary venous bypass graft, associated with compression of the right side of the heart, was revealed. After surgical resection and replacement of the venous graft the patient died due to right ventricular failure. (Neth Heart J 2007;15:252-4.)     

The new era of cardiac surgery: hybrid therapy for cardiovascular disease

Surgical therapy for cardiovascular disease carries excellent long-term outcomes but it is relatively invasive. With the development of new devices and techniques, modern cardiovascular surgery is trending toward less invasive approaches, especially for patients at high risk for traditional open heart surgery. A hybrid strategy combines traditional surgical treatments performed in the operating room with treatments traditionally available only in the catheterization laboratory with the goal of offering patients the best available therapy for any set of cardiovascular diseases. Examples of hybrid procedures include hybrid coronary artery bypass grafting, hybrid valve surgery and percutaneous coronary intervention, hybrid endocardial and epicardial atrial fibrillation procedures, and hybrid coronary artery bypass grafting/carotid artery stenting. This multidisciplinary approach requires strong collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.     

Evaluation of a Novel Laser-assisted Coronary Anastomotic Connector - the Trinity Clip - in a Porcine Off-pump Bypass Model

To simplify and facilitate beating heart (i.e., off-pump), minimally invasive coronary artery bypass surgery, a new coronary anastomotic connector, the Trinity Clip, is developed based on the excimer laser-assisted nonocclusive anastomosis technique. The Trinity Clip connector enables simplified, sutureless, and nonocclusive connection of the graft to the coronary artery, and an excimer laser catheter laser-punches the opening of the anastomosis. Consequently, owing to the complete nonocclusive anastomosis construction, coronary conditioning (i.e., occluding or shunting) is not necessary, in contrast to the conventional anastomotic technique, hence simplifying the off-pump bypass procedure. Prior to clinical application in coronary artery bypass grafting, the safety and quality of this novel connector will be evaluated in a long-term experimental porcine off-pump coronary artery bypass (OPCAB) study. In this paper, we describe how to evaluate the coronary anastomosis in the porcine OPCAB model using various techniques to assess its quality. Representative results are summarized and visually demonstrated.     

Simultaneous off-pump coronary artery bypass grafting and ascending aortobifemoral bypass graft via ventral abdominal route

Aortoiliac disease often coexists with coronary artery disease. It is not uncommon to subject a patient to two separate interventions. We report two cases in which in simultaneous off-pump coronary artery bypass grafting was done with an ascending aortobifemoral bypass graft through the ventral abdominal route without any additional morbidity. Combining a technically simple method of limb bypass with an off-pump cardiac surgery is a promising procedure for revascularization of myocardium and lower limbs. We discuss the merits of combining an off-pump coronary artery bypass grafting procedure with a limb bypass.     

Precision Incision: Robotic Coronary Revascularization via 3.9-cm Minithoracotomy

ABSTRACT: Coronary artery bypass grafting remains the treatment choice for coronary artery disease; but sternotomy, the most commonly used approach, compromises its benefits with postoperative morbidity, higher complication rates, and prolonged length of hospital stay. Despite this, minimally invasive and robotic-assisted technology has not been adopted or widely embraced because supporting literature on robotic-assisted coronary artery bypass grafting is extremely limited. Since 2005, the cardiothoracic surgical team at our institution has been developing and maturing an effective method using robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a minithoracotomy for coronary revascularization. This surgical technique involves precisely placing the robotic endoscopic port immediately over the left anterior descending (LAD) artery target site. The robotically harvested LIMA is secured to the epicardium at the LAD target, the robotic instruments are removed, and the endoscopic port site is enlarged slightly greater than 1 cm to become the minithoracotomy and allow for LIMA-to-LAD anastomosis. The other two robotic ports are used to complete the procedure without a need for additional incisions. This standardized method has been used in more than 750 patients, and since 2009, the last 377 consecutive non-rib-spreading minithoracotomy incisions measured a median of 3.9 cm (mean [SD], 4.16 [1.2748] cm; range, 2.3-12.0 cm). This "How I Do It" article describes our methods in detail and associated robotic nuances.     

冠状动脉支架植入术后行冠脉旁路移植术

目的:总结15例冠状动脉支架植入术后行冠状动脉旁路移植术的临床经验。方法:回顾分析行冠状动脉支架植入术后行冠状动脉旁路移植术15例患者的资料,男10例,女5例,平均年龄(61±5)岁。行冠状动脉支架植入术后再行冠状动脉旁路移植术时间间隔(24±4)月,冠状动脉内置入支架3-6枚,左室射血分数为43%-64%,其中50%为3例。全组行体外循环下冠状动脉旁路移植术3例,行非体外循环心脏跳动下冠状动脉旁路移植术12例。结果:全组共行动脉桥吻合13支,静脉桥33支;围术期并发低心排综合征3例,肺部感染4例,胸腔内出血行胸腔闭式引流术2例,本组患者无死亡病例。术后平均住院日(13±4)天。结论:对冠状动脉内支架植入术后再狭窄或(和)冠状动脉再血管化不足的病例进行冠状动脉旁路移植治疗,可使冠状动脉达到充分再血管化,提高冠心病患者生活质量及预后。     

冠状动脉支架植入术后行冠脉旁路移植术

目的：总结15例冠状动脉支架植入术后行冠状动脉旁路移植术的临床经验。方法：回顾分析行冠状动脉支架植入术后行冠状动脉旁路移植术15例患者的资料,男10例,女5例,平均年龄（61±5）岁。行冠状动脉支架植入术后再行冠状动脉旁路移植术时间间隔（24±4）月,冠状动脉内置入支架3-6枚,左室射血分数为43％-64％,其中〈50％为3例。全组行体外循环下冠状动脉旁路移植术3例,行非体外循环心脏跳动下冠状动脉旁路移植术12例。结果：全组共行动脉桥吻合13支,静脉桥33支;围术期并发低心排综合征3例,肺部感染4例,胸腔内出血行胸腔闭式引流术2例,本组患者无死亡病例。术后平均住院日（13±4）天。结论：对冠状动脉内支架植入术后再狭窄或（和）冠状动脉再血管化不足的病例进行冠状动脉旁路移植治疗,可使冠状动脉达到充分再血管化,提高冠心病患者生活质量及预后。     

Free radical reaction products and antioxidant capacity in beating heart coronary artery surgery compared to conventional bypass

Oxygen-derived free radicals are important agents of tissue injury during ischemia and reperfusion. The aim of this study was to investigate changes in protein and lipid oxidation and antioxidant status in beating heart coronary artery surgery and conventional bypass and to compare oxidative stress parameters between the two bypass methods. Serum lipid hydroperoxide, nitric oxide, protein carbonyl, nitrotyrosine, vitamin E, and β-carotene levels and total antioxidant capacity were measured in blood of 30 patients undergoing beating heart coronary artery surgery (OPCAB, off-pump coronary artery bypass grafting) and 12 patients undergoing conventional bypass (CABG, on-pump coronary artery bypass grafting). In the OPCAB group, nitric oxide and nitrotyrosine levels decreased after reperfusion. Similarly, β-carotene level and total antioxidant capacity also decreased after anesthesia and reperfusion. In the CABG group, nitric oxide and nitrotyrosine levels decreased after ischemia and reperfusion. However, protein carbonyl levels elevated after ischemia and reperfusion. Vitamin E, β-carotene, and total antioxidant capacity decreased after ischemia and reperfusion. Significantly decreased nitration and impaired antioxidant status were seen after reperfusion in both groups. Moreover, elevated protein carbonyls were found in the CABG group. The off-pump procedure is associated with lower degree of oxidative stress than on-pump coronary surgery.     

Cost of surfactant replacement treatment for severe neonatal respiratory distress syndrome: a randomised controlled trial.

OBJECTIVE--To estimate the cost of treating babies with severe respiratory distress syndrome with natural porcine surfactant. DESIGN--Retrospective controlled survey. SETTING--Regional neonatal intensive care unit, Belfast. PATIENTS--33 Preterm babies with severe respiratory distress syndrome who were enrolled in a European multicentre trial during 1985-7. 19 Babies were treated with surfactant and 14 served as controls. INTERVENTIONS--Treatment with natural porcine surfactant. MAIN OUTCOME MEASURE--Cost associated with surfactant replacement treatment per extra survivor in the treatment group and cost per quality adjusted life year for each extra survivor. RESULTS--Fifteen (79%) of the 19 treated babies and five (36%) of the 14 control babies survived. On average, the control babies required 20 days in hospital compared with 61 days for the treated babies (or 95 [corrected] days per extra survivor in the treatment group). The cost per extra survivor in the treatment group was pounds 13,720, with the cost per quality adjusted life year estimated at pounds 710. CONCLUSION--These costs compare favourably with those of established forms of treatment in adults. Thus surfactant replacement treatment for severe respiratory distress syndrome is fairly inexpensive and cost effective.     

体外和非体外循环冠脉搭桥术后老年患者肝肾功能变化

目的:分析常规体外循环冠状动脉搭桥术(CPBCABG)和非体外循环冠状动脉搭桥术(OPCABG)对60岁以上老年患者肝肾功能的变化及意义。方法:根据患者意愿及病情匹配原则将390例60岁以上患者分为常规体外循环下冠状动脉搭桥术组(CPBCABG组)(290例)和非体外循环下冠状动脉搭桥术组(OPCABG组)(100例)。所有患者术前肝肾功能均正常,无严重急性肝、肾功能不全。两组患者在年龄、性别、身体质量指数、体表面积、术前射血分数、术前肝肾功能及手术危险因素等方面无明显差异。两组患者分别于术前第三天和术后第三天抽血测定丙氨酸氨基转移酶(ALT),天冬氨酸转氨酶(AST),肌酐(CR)及尿素氮(BUN)值评价患者肝肾功能。结果:390例患者均进入结果分析。OPCABG组患者术后第3天ALT、AST、CR、BUN明显低于CPBCABG组,差异比较有显著性意义(P<0.05)。结论:冠状动脉搭桥术对肝肾功能均有一定的损害,由于非体外循环冠状动脉搭桥术避免了体外循环对肝肾功能的影响,因此对肝肾功能的损害较轻,减少了术后肝肾功能不全发生的机率。     

Design of a randomized controlled trial of comprehensive rehabilitation in patients with myocardial infarction, stabilized acute coronary syndrome, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting: Akershus Comprehensive Cardiac Rehabilitation Trial (the CORE Study)

Objectives  

1. To assess the long-term effectiveness of a comprehensive cardiac rehabilitation programme on quality of life and survival in patients with a large spectrum of cardiovascular diseases (myocardial infarction, acute coronary syndrome, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). 2. To establish the degree of correlation between expected improvement of health-related quality of life and improvement in physical function attributable to rehabilitation in the intervention group, in comparison with similar changes in the conventional care group.     

Endoscopic lesser saphenous vein harvesting for coronary artery bypass grafting: first reported case

Endoscopic vessel harvesting has become a widely used modality for harvesting venous and arterial conduits for coronary artery bypass grafting. Specifically, it has been used to harvest the greater saphenous vein, internal thoracic artery, and the radial artery. A case of endoscopic lesser saphenous vein harvesting for coronary artery bypass grafting is reported.     

左旋精氨酸在冠脉搭桥术中心肌保护作用研究进展

冠状动脉搭桥术(Coronary artery bypass grafting,CABG)中发生心肌缺血再灌注损伤是难以避免的,而冠状动脉内皮损伤导致一氧化氮(nitrogen monoxidum NO)合成及释放减少是导致心肌缺血/再灌注损伤(Myocardial ischemia/reperfusion injury MI/RI)的重要因素。本文通过对左旋精氨酸(left-arginine,L-Arg)与NO、MI/RI之间的联系、L-Arg对MI/RI的保护作用及其机制、L-Arg-NO的心肌保护作用与剂量之间关系以及L-Arg在CABG中的临床应用等方面的研究进行综述,阐明提供外源性L-Arg通过L-Arg-NO通路促进体内NO的合成及释放,探讨左旋精氨酸在冠脉搭桥术中心肌保护作用的可行性。     

Dextrocardia with situs inversus totalis: Cardiovascular surgery in three patients with concomitant coronary artery disease

Three patients with situs inversus totalis (mirror-image dextrocardia) and concomitant coronary artery disease were admitted to our institution for evaluation. In all cases, aortocoronary bypass grafting was successful. Patients with situs inversus and mirror-image dextrocardia are believed to have normal longevity, and, as these studies suggest, they have the same long-term prognosis after coronary bypass grafting as patients with situs solitus.     

肥厚梗阻性心肌病的外科治疗

目的:总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法:2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均(42.7±13.6)岁;左室流出道压差(LVOTGP)70～120 mmHg(1 mmHg=0.133Kpa),平均(95.0±22.6)mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术(MVR)7例,二尖瓣成形术(MVP)7例,二尖瓣、主动脉瓣成形术(MVP+AVP)5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术(MVP+AVP+CABG)2例。分析比较病人术前超声心动图(UCG),术中经食管心脏超声(TEE),以及术后1周、3月、6月、1年超声心动图结果。结果:手术死亡1例(3.0%,1/33例),主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例(3.0%,1/33例)。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象(SAM征)消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论:外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。