Neurological complications of coronary artery bypass graft surgery: six month follow-up study.

As part of a major prospective study of the neurological complications of coronary artery bypass graft surgery patients were reviewed over six months to determine the clinical course and functional impact of early postoperative complications. One hundred and ninety one out of 312 (61%) patients had developed early postoperative disorders. At six months 165 of the 191 patients with early neurological complications were reviewed. Of the 165, 85 still had detectable neurological signs, but these were often minor and of little functional importance. Only 10 patients had neurological disability at six months, and this was major in only four patients, all of whom had suffered major perioperative stroke. No patient with non-disabling neurological complications in hospital became functionally impaired on returning home. Neurological disorders are not a major cause of failure to return to work by six months after coronary artery bypass surgery. Of 139 patients who were of working age and had not returned to work by six months, only four were prevented by neurological injury related to surgery. The long term prognosis for early neurological disorders after coronary artery bypass surgery is usually favourable, except in those patients who have sustained major perioperative stroke.     

Early neurological complications of coronary artery bypass surgery.

A prospective study of 312 patients undergoing elective coronary artery bypass surgery was undertaken to determine the incidence, severity, and functional impact of postoperative neurological complications. Detailed evaluation of the patients showed that neurological complications after surgery were common, occurring in 191 of the 312 patients (61%). Although such a high proportion of the total developed detectable changes, serious neurological morbidity was rare. Neurological disorders resulted in death in only one patient (0.3%) and severe disability in only four (1.3%). Forty eight patients were mildly disabled during the early postoperative period, and the remaining 138 with neurological signs had no serious functional disability. The postoperative neurological disorders detected included one death from cerebral hypoxic damage. Prolonged depression of conscious level was observed in 10 patients (3%) and definite stroke in 15 (5%); 78 (25%) developed ophthalmological abnormalities and 123 (39%) primitive reflexes; postoperative psychosis was observed in four (1%); and 37 (12%) developed disorders of the peripheral nervous system. The incidence of serious neurological problems such as fatal cerebral damage, stroke, and brachial plexopathy is in accordance with experience elsewhere. Lesser abnormalities, whose detection required detailed neurological examination, were much commoner than expected from previous reports.     

The sheep as a model for coronary artery bypass surgery

The sheep is considered to be a suitable model for cardiovascular surgery because of its ease of handling, size, and vascular anatomy which bears close resemblance to the human. Several difficulties, however, have limited the use of the sheep for such a purpose-mainly the high infection rate resulting from median sternotomy incision and its susceptibility to intractable ventricular fibrillation (VF) with the slightest manipulation of the heart, and even the risk of short periods of myocardial ischaemia. We have used the sheep model extensively to perform coronary artery bypass surgery and were successful in overcoming these difficulties. Fifty-seven adult female sheep were used to test a new anastomotic device for the creation of a sutureless connection between venous and arterial grafts and the coronary arteries. The study required full access to the heart and great vessels and mobilization of one of the internal mammary arteries. Changing to the left lateral thoracotomy (LLT) approach solved the initial fatal problems of postoperative infected median sternotomy incisions. Aggressive prophylactic treatment with anti-arrhythmic drugs, maintenance of normothermia and myocardial preconditioning rendered the heart much less vulnerable to manipulations and ischaemia. These measures have reduced the mortality rate from 45% to 0% (P <0.0001). With specific operative techniques and pharmaceutical interventions, the sheep can be effectively and safely used as a model for coronary artery surgery.     

Alterations in plasma angiogenic growth factor concentrations after coronary artery bypass graft surgery: relationships with post-operative complications

To determine whether angiogenic growth factor levels are altered during and after cardiac surgery, plasma concentrations of basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF) and transforming growth factor beta1 (TGFbeta1) were measured in 32 patients undergoing coronary artery bypass graft (CABG) surgery with extracorporeal circulation (ECC). EGF levels significantly decreased during ECC and remained low until the 24th post-operative hour with no difference between complicated and uncomplicated patients. TGFbeta1 and bFGF concentrations significantly increased at the end of ECC and after cross-clamp release, and returned to pre-operative values at the 6th post-operative hour suggesting that the source of these elevations are the lungs and heart. After cross-clamp release bFGF levels but not TGFbeta1 ones were higher in patients with respiratory impairments. VEGF values increased significantly at the 6th and 24th post-operative hours. At the 24th post-operative hour plasma VEGF levels were higher in patients with cardiovascular and hematological impairments. In conclusion, these results highlight that the angiogenic network is profoundly altered in patients undergoing cardiopulmonary bypass as previously demonstrated for lipidic, cytokine and haematopoietic growth factor ones and identify an association between specific post-CABG complications and systemic release of bFGF and VEGF.     

Predictors of postoperative atrial fibrillation after coronary artery bypass graft surgery

Objectives

The present study was aimed to identify the preoperative, intraoperative, and postoperative predictors of AF in a pure cohort of the patients with coronary artery disease who underwent CABG surgery.

Methods

Between November 2005 and May 2006, 302 consecutive patients were included in this prospective study. All the relevant clinical, electrocardiographic, echocardiographic, and laboratory data were gathered in the included patients and they were also monitored for development of post-CABG AF.

Results

Postoperative AF occurred in 46 (15%) of patients. By univariate analysis, older age, P-wave abnormality in ECG, presence of mitral regurgitation, larger left atrium (LA), left main coronary artery involvement, failure to graft right coronary artery (RCA), and adrenergic use in ICU were significantly associated with occurrence of post-CABG AF (all P< 0.05). However, in the logistic regression model, age (OR: 1.067, 95%CI: 1.02-1.116, P=0.005), LA dimension (OR: 1.102, 95%CI: 1.017-1.1936, P=0.017), P-wave morphology (OR: 12.07, 95%CI: 3.35-48.22, P=0.0001), failure to graft RCA (OR: 3.57, 95%CI: 1.20-10.64, P=0.022), and postoperative adrenergic use (OR: 0.35, 95%CI: 0.13-0.93, P=0.036) remained independently predictive of postoperative AF.

Conclusion

The present study suggested that age, P-wave morphology, LA dimension, failure to graft right coronary artery, and postoperative adrenergic use were independent predictors of post-CABG AF. Therefore, clinical data, ECG and echocardiography may be useful in preoperative risk stratification of the surgical patients for the occurrence of post-CABG AF.     

The current status of anastomotic devices for coronary artery bypass surgery

The purpose of this article is to briefly review the history of proximal and distal anastomotic devices and to discuss presently available devices. Clinical outcome data from the EPIC Trial of the Cardica PAS-Port Proximal Anastomosis System will also be presented.     

Influence of preoperative variables upon the results of coronary artery bypass surgery

One thousand ninety-six consecutive patients who received aorta-to-coronary artery bypass vein grafts were followed up to 4 years postoperatively. The early mortality was 1.7%; the 4-year survival rate, computed by actuarial methods, was 93.1%; the incidence of peri-operative myocardial infarction was 1.9%. After 4 years, 94.4% of the patients were free of peri- and postoperative infarcts. Angina pectoris was relieved in 85.7% and eliminated in 62.8% of the survivors. An analysis of the effects of ten preoperative variables on operative results showed that operative risk (early mortality, perioperative myocardial infarction) was not influenced by any of the variables. Late results (4-year mortality, 4-year infarction rate), however, were negatively affected by impaired ventricular function. Symptomatic improvement was more pronounced in men than in women.     

Tetraplegia after coronary artery bypass surgery in a patient with cervical herniation

Tetraplegia is a rare complication after coronary artery bypass surgery. The authors present a case of tetraplegia after uncomplicated coronary artery bypass surgery because of cervical disc herniation. No distinct abnormality was found in the preoperative neurologic examination although the postoperative cervical magnetic resonance imaging revealed a huge hernia at C5-C6 level presenting with tetraplegia. Surgical decompression was performed on the second postoperative day of bypass surgery, and neurologic deficits gradually improved.     

80岁以上老年人冠状动脉旁路移植术合并瓣膜置换手术的临床分析

目的:总结老年患者行冠状动脉旁路移植术(CABG)合并瓣膜置换(VR)手术的特点及经验。方法:上海交通大学附属第一人民医院心血管外科2001年11月至2010年3月对60例年龄大于80的患者施行冠状动脉搭桥+瓣膜置换手术,男33例,女27例。年龄80-87岁,平均年龄(83.77±2.45)岁。均为冠心病合并瓣膜病变患者。其中36例患者行冠状动脉旁路移植+二尖瓣置换手术,15例患者行冠状动脉旁路移植+主动脉瓣置换手术,9例患者行冠状动脉旁路移植+双瓣置换手术,同时8例患者行三尖瓣成形手术,3例患者行射频消融手术,1例升主动开成形术。置换生物瓣膜者51例,置换机械瓣膜者9例。CABG平均搭桥(2.13±0.75)根,搭桥材料为左乳内动脉与大隐静脉。结果:全组早期死亡9例(15%),1例死于术后出血,1例死于多器官功能衰竭,7例死于术后心衰。早期生存51例(85%),出现术后并发症10例,其中2例发生胸腔积液,1例心包填塞,3例肺部感染,1例心房扑动后发生室颤,3例二次开胸止血。给予相应对症治疗后痊愈出院。门诊随访49例,随访时间1～60个月,心功能I级2例、Ⅱ级29例、Ⅲ级18例、Ⅳ级0例(NYHA分级)。结论:对老年患者行冠脉搭桥+瓣膜置换手术,只要掌握手术适应证,充分作好术前准备、术中及术后处理,手术治疗可以取得良好效果。     

80岁以上老年人冠状动脉旁路移植术合并瓣膜置换手术的临床分析

目的：总结老年患者行冠状动脉旁路移植术（CABG）合并瓣膜置换（VR）手术的特点及经验。方法：上海交通大学附属第一人民医院心血管外科2001年11月至2010年3月对60例年龄大于80的患者施行冠状动脉搭桥＋瓣膜置换手术,男33例,女27例。年龄80-87岁,平均年龄（83.77±2.45）岁。均为冠心病合并瓣膜病变患者。其中36例患者行冠状动脉旁路移植＋二尖瓣置换手术,15例患者行冠状动脉旁路移植＋主动脉瓣置换手术,9例患者行冠状动脉旁路移植＋双瓣置换手术,同时8例患者行三尖瓣成形手术,3例患者行射频消融手术,1例升主动开成形术。置换生物瓣膜者51例,置换机械瓣膜者9例。CABG平均搭桥（2.13±0.75）根,搭桥材料为左乳内动脉与大隐静脉。结果：全组早期死亡9例（15%）,1例死于术后出血,1例死于多器官功能衰竭,7例死于术后心衰。早期生存51例（85%）,出现术后并发症10例,其中2例发生胸腔积液,1例心包填塞,3例肺部感染,1例心房扑动后发生室颤,3例二次开胸止血。给予相应对症治疗后痊愈出院。门诊随访49例,随访时间1～60个月,心功能I级2例、Ⅱ级29例、Ⅲ级18例、Ⅳ级0例（NYHA分级）。结论：对老年患者行冠脉搭桥＋瓣膜置换手术,只要掌握手术适应证,充分作好术前准备、术中及术后处理,手术治疗可以取得良好效果。