Risks and benefits of aortocoronary bypass surgery in patients aged 65 years or more.

Between January 1970 and July 1978, 85 patients aged 65 years or more underwent aortocoronary bypass surgery at the Montreal Heart Institute. The mortality during the operation and the first 29 days thereafter was 12% overall, but was only 5% when the myocardium was protected by the use of cold cardioplegic solutions. Of the 75 patients who survived this period 7 (9%) had a perioperative transmural myocardial infarction. Nonfatal noncardiac complications were more common in these patients than in younger patients, but did not lead to permanent deficits. Three patients died after discharge from hospital, two of cardiac causes. Only one patient had a nonfatal myocardial infarction after discharge. The actuarial 5-year survival rate for all the patients was 80%. After a mean follow-up period of 30 months the condition of 94% of the patients was improved by at least one class of the New York Heart Association functional classification, and 68% were asymptomatic. It is concluded that aortocoronary bypass surgery can be performed in selected older patients with a relatively low in-hospital mortality and morbidity. Symptomatic improvement occurs in almost all such patients. Cardiac catheterization and aortocoronary bypass surgery should therefore be performed in selected older patients with severe angina that is refractory to optimum medical therapy.     

Return to work and quality of life after surgery for coronary artery disease.

Changes in work capability and quality of life were assessed retrospectively in 130 patients with ischaemic heart disease who had undergone aortocoronary bypass operations during 1976-7 because of medically uncontrollable angina. A total of 85 patients (65.4%) reported complete relief from angina six months after operation, though 12 later suffered a recurrence. Substantially fewer patients needed drugs after the operation. Before operation 9 out of 117 men fully employed at the onset of angina were working without restriction or doing lighter, fulltime work, 38 were at work but seriously incapacitated by angina, and 70 were forced to stop work. After operation 70 were working without restriction or engaged in lighter work, 15 were at work but still restricted by angina, and only 32 were forced to stop work. This result was highly significant (P less than 0.001). These differences were even more pronounced in heavy manual workers, of whom none cobld work normally before operation, whereas 16 were working without restriction afterwards. Of patients wishing to engage in hobbies or sports, social activity, and sexual intercourse but were restricted before operation, about two-thirds could resume these activities afterwards. Coronary artery surgery provided dramatic symptomatic relief in up to 90% of patients and permitted rehabilitation and return to gainful employment irrespective of type of labour. The degree of symptomatic improvement and increase in exercise tolerance after successful surgery is usually far greater than occurs with any other form of treatment and directly improves quality of life and work capability.     

Left ventricular aneurysm: Twenty-year surgical experience with 1572 patients at the Texas Heart Institute

From January 1958 through December 1979, 1572 patients underwent surgery for left ventricular aneurysm (LVA) in our institution. The series included 1365 men and 207 women, with a ratio of 6.5:1. Ages ranged from 25 to 79 years, with a mean of 54.7 years. Most patients were in NYHA functional Class III or IV, and all had sustained at least one documented myocardial infarction. During the first decade, LVA resection alone was performed, but after the advent of aortocoronary bypass (ACB) surgery, the majority of patients underwent ACB along with LVA resection. Some required additional septoplasty, mitral valve replacement, annuloplasty, or aortic valve replacement. In all groups, the mortality was higher for women than for men. Early deaths were due primarily to acute or progressive myocardial failure secondary to recurrent myocardial infarction. Follow-up information for 6 months to 8 years was obtained by means of questionnaires submitted to patients and referring physicians. Of 475 patients who underwent LVA resection and ACB and who responded, 92.2% were either improved or asymptomatic.     

Capacities of multidetector spiral computed tomography in the planning and postoperative examination of patients undergoing coronary artery bypass surgery

Multiple investigations show that multidetector spiral computed tomography (MSCT) bypass grafting becomes an alternative to invasive coronary angiography in detecting coronary graft stenoses and occlusions. The investigation retrospectively estimated the patency of aortocoronary and mammary coronary artery anastomoses by MSCT bypass grafting. Examinations were made in 85 (326 anastomoses) patients who had undergone aortocoronary and mammary coronary artery bypass surgery and had MSCT bypass grafting within 3 years after the surgery. In the first year following the surgery, 18 patients with graft stenotic changes, as evidenced by MSCT, underwent intervention coronary angiography, the sensitivity and specificity of which was 100%. The results of clinical and instrumental examinations were also compared with graft incompetence, as shown on MSCT that revealed that MSCT bypass grafting was the only noninvasive technique to evaluate early coronary graft closure both in the absence of clear signs of myocardial ischemia according to the data of exercise tests and in the presence of recurrent angina pectoris.     

Unemployment and mortality among Finnish men, 1981-5.

OBJECTIVE--To ascertain whether, after controlling for several relevant background variables simultaneously, unemployment is related to mortality and to assess whether this relation is causal or whether unhealthy people are more likely to become unemployed. DESIGN--Prospective study of mortality in Finland during 1981-5 based on 1980 census data on 30-54 year old wage earner men and with particular attention to unemployment in the year before the census. SETTING--Research project at the University of Helsinki. SUBJECTS--All wage earner men in Finland aged 30-54 at the 1980 census. MAIN OUTCOME MEASURES--Causes of death during 1981-5 and duration of unemployment in the year before the census. Background variables controlled for were age, socioeconomic state, marital state, and health. The data were analysed by log linear regression models. RESULTS--During the study period 1981-5, which covered almost 2.7 million person years, there were 9810 deaths. After controlling for all background variables relative total mortality among unemployed versus employed men was 1.93 (95% confidence interval 1.82 to 2.05). The excess mortality was highest in accidental and violent causes of death (relative mortality 2.51; 95% confidence interval 2.28 to 2.76). For circulatory diseases the relative death rate was 1.54 (95% confidence interval 1.40 to 1.70), but among neoplasms only lung cancer was associated with excess mortality. Selection for unemployment based on age, socioeconomic state, and marital state was evident but no such selection was detected based on health. Effects of unemployment on mortality were more pronounced with increasing duration of unemployment. CONCLUSIONS--The relative excess mortality of unemployed men in Finland cannot fully be explained by demographic, social, and health variables preceding unemployment. Unemployment therefore seems to have an independent causal effect on male mortality. Further studies are needed to elucidate the mechanisms between unemployment and mortality.     

Late results of aortocoronary bypass grafts in 100 patients with stable angina pectoris

From March 1969 to December 1972, 314 patients underwent elective aortocoronary saphenous vein bypass graft surgery at the Toronto General Hospital for the relief of stable disabling angina refractory to medical management. Inhospital mortality was 2.5%. Of these patients 100 agreed to return for follow-up hemodynamic and angiographic assessment at a mean interval of 19.7 months after operation. Seventy-four percent of patients were asymptomatic or had angina only with strenuous exertion at the time of follow-up. Seventy-five percent of the 142 grafts were patent, though a few had significant narrowings. Clinical improvement could be correlated with successful myocardial revascularization. Myocardial infarction was diagnosed by the presence of new Q waves after operation in 15% of patients. Many of these patients had patent grafts at follow-up and all were improved. Dyslipoproteinemia was not found to be a factor affecting late graft patency. Total left ventricular function was not shown to be improved by segmental revascularization. The trend toward improved survival in the intervening period for the total operated group is encouraging.     

Evolution précoce et tardive après pontage aortocoronarien: expérience de 500 cas.

Between 1971 and 1976, 500 patients underwent aortocoronary bypass surgery. There were 15 operative deaths (3%) and the total frequency of perioperative infarction was 7%. The operative mortality was 7.4% in unstable angina, as compared with 1.1% in stable angina (P less than 0.01). The proportion of grafts patent at 2 weeks was 92% and at 18 months 87.6%. Postoperative follow-up was complete for 99% of the patients. There were 15 late deaths (3%) and the rates of survival at 2 and 4 years were 94.4% and 92.1% respectively. The actuarial curve of survival after surgery was not significantly different from that of the general population. After a mean follow-up of 27 months 73% of the patients were completely free of angina and 19% were markedly improved. The rate of recurrence of angina averaged 10% per year and the annual infarction rate was 0.7%. Fourteen patients (3%) underwent reoperation during the follow-up period. Thus, coronary revascularization surgery offers effective and sustained relief of incapacitating angina and might also improve survival if the operative mortality is low.     

Emergency aorto-coronary venous bypass graft in cardiogenic shock

The mortality rate of shock complicating myocardial infarction is extremely high (80-100%) despite intensive medical management. Five patients with acute myocardial infarction and cardiogenic shock received an emergency aorto-coronary bypass graft, from three hours to five days after the onset of infarction and three to nine hours after the onset of shock. Selective coronary angiography was performed in all cases prior to operation. Four of the five patients survived and were discharged from hospital. Two cases with A-V dissociation and complete heart block reverted to normal sinus rhythm after the operation. This limited experience indicates that emergency aortocoronary bypass graft surgery can reduce mortality significantly in properly selected cases of cardiogenic shock.     

The first 1000 coronary artery repair operations in Toronto

The present status of the aortocoronary bypass procedure is described in general terms by a review of the first 1040 patients who received this operation in Toronto, before November 15, 1973. The operative risk was related to the status of the left ventricular function. In those with fair or good ventricular function the risk of hospital mortality was less than 3% in the entire series and less than 2% in the past year. Advances in investigative and surgical techniques have allowed this operation to become an increasingly safe, effective and recommended procedure for patients suffering from medically intractable angina pectoris. The operation has been of great benefit to such individuals. In addition it has been an effective stimulus to research and development in Canadian cardiology and cardiovascular surgery.     

透明角膜切口白内障术后角膜曲率的临床观察*

目的:观察年龄相关性白内障行透明角膜切口超声乳化吸除及人工晶体植入术后角膜曲率的变化及相对稳定的时间。方法:收集2016年6月-8月在哈尔滨医科大学附属第一医院伍连德纪念医院进行的3.0 mm透明角膜切口白内障超声乳化吸除及人工晶体植入术的患者200例216眼,其中男88例、女128例,平均年龄71.2岁,进行相应的术前检查,并检查术前、术后第一天、一周、一个月、和三个月时的角膜曲率、视力、眼压并行相应的统计学分析。结果:术后不同时间点视力0.5的恢复情况:第一天为147眼(68.05%)、一周为175眼(81.02%)、一个月为193眼(89.35%)、三个月为197眼(91.20%);术前角膜曲率为43.94±1.35、术后第一天、术后一周的角膜曲率分别为44.98±1.06、44.45±1.18,与术前相比有显著性差异(p0.05),术后一个月、三个月的角膜曲率分别为44.13±1.27、44.02±1.24,与术前相比无显著性差异(p0.05);术源性散光于术后一天达到最大,随后逐渐减小,术后一个月、三个月与术后一天比较有显著性差异(p0.05),术后三个月与一个月比较无显著性差异(p0.05),术源性散光术后逐渐下降,并于一个月时趋于稳定。结论:3.0 mm透明角膜切口白内障超声乳化吸除及人工晶体植入术患者在术后一个月的角膜曲率基本稳定,恢复至术前状态,屈光状态趋于稳定,术源性角膜散光较小,术后视力恢复至较好状态。     

Scientific Section: Coronary Artery Surgery,Task Force Appointed by the Conference of Deputy Ministers of Health: 2. Results,indications and recommendations

The large majority of reported studies of patients treated by aortocoronary bypass have not been randomized clinical trials, and hence must be interpreted with great caution.Review of the seven randomized clinical trials in the literature leads to only one firm, positive conclusion: aortocoronary bypass results in a reduction in the morbidity of coronary artery disease, due to the alleviation of cardiac pain, for at least 3 years. In addition, there is some evidence that mortality for symptomatic patients with significant left main-stem coronary artery stenosis may be reduced by coronary artery bypass surgery. A significant effect on mortaliy form other forms of coronary artery disease has not yet been conclusively demonstrated but also has not been excluded. Most of the reports are preliminary and involve small numbers of patients followed for relatively short periods. The operation is still being improved. It is to be hoped that the randomized trials, involving large numbers of patients, now in progress will supply some of these answers.Aortocoronary bypass surgery is the treatment of choice for patients with stable cardiac pain that is disabling despite adequate treatment, or when adequate treatment is impractial; for patients with unstable cardiac pain, uncontrolled despite adequate treatment; and for symptomatic patients with critical stenosis of the left main-stem coronary artery.     

骨性Ⅲ类错合畸形患者正颌术后呼吸道情况随访调查

目的：通过评估骨性Ⅲ错合畸形患者正颌手术后睡眠时期的呼吸功能情况,研究该类患者正颌手术后存在呼吸道梗阻的可能性。为临床治疗提供依据。方法：分析56例接受正颌手术的骨性Ⅲ类错合畸形患者的术前及术后1周、1月、3月和术后6月的多导睡眠图报告。设计问卷调查表评估手术影响日间嗜睡度的变化。从PSG报告上获得的术前术后有代表性的2项参数睡眠呼吸暂停低通气指数与最低氧饱和度分别进行比较。结果：数据显示术前和术后AHI指数及SpO2无显著性差异（统计学上无差异）。54例病人术后均未出现睡眠呼吸障碍症状。2例病人术后出现睡眠时期打鼾,但术后随访6月后打鼾逐渐消失。结论：骨性Ⅲ类错合畸形患者正颌术后无明显呼吸道梗阻症状。但若患者同时具有超重、短颈、舌体大等其他危险因素及仅行下颌骨后退手术可能导致睡眠呼吸暂停低通气综合症的发生。     

Selection and care of cardiac patients for plastic surgery

A major operation after successful coronary artery bypass surgery has been proved as safe as an operation for a patient free from coronary artery disease. Most patients with angina who demonstrate an operable coronary lesion should usually be scheduled for coronary artery bypass before undergoing nonemergency surgery. It is advisable to postpone elective plastic surgery for 6 weeks to 3 months after coronary bypass and 6 months after myocardial infarction. The life expectancy of cardiac patients must be carefully considered before elective plastic surgery, because performing an operation on a patient who cannot live to enjoy the benefits is unwise. Working together, cardiac surgeons, cardiologists, and plastic surgeons can now prolong the quantity of life and enrich its quality in properly selected and carefully managed patients.     

To serve you better

Fasting blood lipids were analyzed shortly before revascularization surgery in an attempt to find a possible correlation between the fate of the aortocoronary saphenous vein graft and lipoproteinemia. The patency of the bypass was evaluated by arteriography at two weeks and at one year following operation. Patients with closed grafts at two weeks had an original mean serum triglyceride concentration of 287 mg./100 ml. Patients with grafts which were widely patent after one year had an original triglyceridemia of 224 mg./100 ml. The severely stenosed group had an intermediate average preoperative value of 224 mg./100 ml. The same conclusion was reached with a group of patients with good vessel(s) distal to the graft(s). Cholesterolemia was about the same in all groups. These results suggest the hypothesis that hypertriglyceridemia plays a significant role in the reduction and/or occlusion of the lumen of the vein graft.     

MYOCARDIAL INFARCTION FOLLOWING CAROTID ENDARTERECTOMY

Myocardial infarction has been the major cause of mortality following operation for cerebrovascular insufficiency. In our institution, a clinical diagnosis of coronary artery disease was made in 37 of 125 (29.6%) consecutive male patients having carotid endarterectomy. Six of these 37 patients developed postoperative myocardial infarction. In contrast, none of the 88 patients without coronary artery disease developed myocardial infarction. A more recently treated group of 20 patients who had undergone carotid artery surgery and had previously undergone coronary artery bypass for angina did not develop postoperative myocardial infarction. These data suggest that in patients with both coronary artery and carotid artery disease, prior or concomitant coronary artery bypass should be considered. Myocardial infarction has been the leading cause of early and late death following operation for cerebrovascular insufficiency.(1) DeBakey(2) found operative mortality in patients having surgery for cerebrovascular insufficiency directly related to the incidence of coronary artery disease. An increased operative mortality due to reinfarction has been found in patients recovering from recent myocardial infarction.(3) Cooley(4) found that in patients having aortocoronary bypass there was no increased operative mortality 30 days after myocardial infarction and this may apply to patients having carotid endarterectomy. Subendocardial postoperative infarction associated with minor T wave changes and slight enzyme elevation had a better prognosis than did transmural infarction causing significant Q waves, sequential ST and T wave changes and marked enzyme elevations.(5) The purpose of this study was to document our experience with myocardial infarction in patients undergoing carotid artery operation for clinical coronary artery disease. Consideration of the role of saphenous vein bypass in those patients with coronary artery disease was the background for this review even though the evidence that myocardial infarction can be prevented with saphenous vein bypass operation is only preliminary at the present time.(6)     

Influence of aortocoronary bypass surgery on employment.

Aortocoronary bypass operations are expensive. Economic benefit might be derived if such operations influenced the ability of persons with symptomatic coronary artery disease to be employed. Follow-up data were obtained for 329 survivors of bypass operations 2 to 60 months (mean, 22.9 months) postoperatively; 178 had been working prior to the operation and 213 were working at the time of follow-up, for a net gain of 35 employed patients. Therefore, bypass surgery does lead to a small but significant increase in the proportion of angina patients who are employed.     

Gastric Bypass in a Low‐Income,Inner‐City Population: Eating Disturbances and Weight Loss

Objective: To examine the prevalence of eating disturbances and psychiatric disorders among extremely obese patients before and after gastric bypass surgery and to examine the relationship between these disturbances and weight outcomes. Research Methods and Procedures: Sixty‐five women patients (ages 19 to 67) with a mean BMI of 54.1 were assessed by semistructured psychiatric interview before surgery and by telephone interview after surgery (mean follow‐up: 16.4 months) to determine psychiatric status, eating disturbances, and weight and health‐related variables. Results: Patients lost a mean of 71% of their excess BMI, with significantly poorer weight loss outcomes among African Americans. Psychiatric disorders remained prevalent before (37%) and after (41%) surgery. In contrast, binge eating disorder dropped from 48% to 0%. Psychiatric diagnosis did not affect weight outcomes. Instead, more frequent preoperative binge eating, along with greater initial BMI, follow‐up length, and postoperative exercise, predicted greater BMI loss. Postsurgical health behaviors (exercise and smoking) and nocturnal eating episodes were also linked to weight loss. Exercise frequency increased and smoking frequency tended to decrease after surgery. Discussion: These findings indicated that eating and psychiatric disturbances did not inhibit weight loss after gastric bypass and should not contraindicate surgery. Prior binge eating, eliminated after surgery, predicted BMI loss and, thus, may have previously been a maintaining factor in the obesity of these patients. The association between health behaviors and outcome suggests possible targets for intervention to improve surgical results. Poorer outcomes among African Americans indicate that these patients should be closely monitored and supported after surgery.     

Prediction of Hypothyroidism after Partial Thyroidectomy for Thyrotoxicosis

Hypothyroidism is one of the major complications after thyroidectomy for thyrotoxicosis, but the factors responsible are not well defined. In an attempt to define these factors 278 patients operated on in 1965-9 were studied in detail. The overall incidence of hypothyroidism was 49%. The high incidence of hypothyroidism during 1965-6 led to a policy of leaving larger remnants in the later years of the study, and it became apparent that the most important aetiological factor in postoperative hypothyroidism was small remnant size. There seemed to be an association between the incidence of hypothyroidism and the presence of antithyroglobulin antibodies, but this association was not statistically significant. The data suggested that blood group O might be more common and blood group A less common in hypothyroid patients. The incidence of hypothyroidism seemed to be uninfluenced by the age or sex of the patient, the size of the gland, or the amount and duration of preoperative antithyroid drug therapy.Though a reasonable prediction of the incidence of hypothyroidism can be made for a group of patients on the basis of remnant size, the fate of the individual can be predicted only within very wide limits. An indication of the future status of the individual patient at one year and subsequently does, however, seem possible from serum protein-bound iodine estimations at one and four months after operation. Hypothyroidism developing later than one year after operation has not been observed in this series. The ability to assess thyroid status early after surgery is of some merit in the long-term supervision of the postoperative thyrotoxic patient, and in this respect surgical treatment seems to have some advantage over radioiodine therapy.     

胃转流术治疗非肥胖T2DM 术后1 年血糖代谢变化的研究

目的:评价胃转流术(RYGP)治疗非肥胖2型糖尿病(T2DM)的1年血糖代谢变化,并探讨术前T2DM病史对术后1年效果的影响。方法:收集我科2009年6月～2010年4月期间60例行RYGP的非肥胖T2DM患者术前及术后1年内的一般资料,临床及实验室检查数据等。根据T2DM病史分为两组:Ⅰ组:≤5年;Ⅱ组:5-10年,两组体质指数(BMI)均<30 kg/m2。术后6M、12M主要随访:空腹血糖(FPG)、餐后2h血糖(2hPG)、体重、BMI、糖化血红蛋白(HbA1c)、空腹血清胰岛素(Fins)、空腹C肽(C-P)、胰岛素抵抗指数和用药情况,采用SPSS17.0软件进行手术前后对照与组间对照分析。结果:与术前相比,Ⅰ组术后6M、12M时FPG,2hPG,体重,BMI,C-P,HbA1c,Fins均明显改善(P<0.05),HOMA-IR在术后6M无显著差异(P>0.05),术后12M有显著差异(P<0.05);Ⅱ组术后6M、12M时与术前相比,FPG,2hPG,体重,BMI,C-P,HbA1c,HOMA-IR均明显改善(P<0.05),Fins在术后6M、12M与术前相比无显著差异(P>0.05)。Ⅰ组和Ⅱ组于术后6M、12M在FPG、2hPG、体重、BMI、C肽、Fins、HbA1c、HOMA-IR、用药以及手术缓解率方面均无显著差异(P>0.05)。结论:非肥胖T2DM患者胃转流术后1年血糖代谢明显改善,术后完全缓解率逐步增高,术前T2DM病史(≤5年与5-10年)对术后1年效果的影响无显著差异。     

Coronary artery surgery.

Coronary artery disease has been described as the largest public health problem in Western society. In spite of the many advances in recent years in its medical management, many patients remain disabled even after optimal medical therapy. The aortocoronary bypass operation, introduced in the mid-1960s, has been shown to have consistent subjective and objective effects on the course of the disease in a large proportion of patients. The procedure consists of inserting a portion of the saphenous vein into both the aorta and a coronary artery to bypass the obstruction. It is usual now to bypass obstructions in several coronary arteries at the same operation if necessary. The prognosis for patients with ischemic heart disease with medical management depends on the extent of the disease. Patients with obstruction of only one coronary artery have a prognosis very little different from normal. On the other hand, obstruction of several arteries is consistently associated with a mortality approaching or exceeding 10% per year.