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BACKGROUND: Apart from smaller native coronary arteries a lower number of anastomoses and a lower ITA incidence have been suggested as being responsible for the increased mortality in female patients compared to males. The aim of this study was to clarify whether the outcome of females might be a consequence of a different regimen in anastomosis and ITA frequency. METHODS: We evaluated operative data and early outcome of 6906 patients with isolated CABG operated between 1/96 - 7/03 3064 out of 5381 males received bilateral ITA (BITA) vs. 750 of 1525 females. Single ITA (SITA) was performed in 2126 males and 704 females. RESULTS: Demographic and operative data: average age for male patients was 64.0 ± 9.2 years, for females 68.5 ± 8.6 years ( p < 0.05). The prevalence of diabetes mellitus was significantly higher in females (34.6 % vs. 27.4 %, p < 0.01). Body mass index (BMI, 26.6 vs. 27.4 mean), incidence of main stem stenosis (23.0 % vs. 23.5 %), ejection fraction < 40 % (7.8 % vs. 10.1 %), urgent or emergent operations (13.1 % vs. 11.3 %) and number of performed anastomoses (3.2 vs. 3.5 mean) showed no significant difference between males and females. Total ITA frequency did not differ (95.3 % vs. 96.5 %), but BITA frequency was significantly higher (56.9 % vs. 49.2 %, p < 0.01) in male patients. Overall 30-day mortality was 2.8 % for males vs. 4.1 % ( p < 0.05) for females. Cardiac-related mortality was significantly higher in female patients (2.6 % vs. 1.1 %, p < 0.01). Non-cardiac-related mortality did not differ significantly. Graft-related mortality for males and females revealed 2.7 % in the BITA, 3.3 % in the SITA group and 6.9 % for patients without ITAs and reached statistical significance ( p < 0.01) for SITA or BITA vs. the no-ITA group, but not for BITA vs. SITA grafting. Nevertheless cardiac-related mortality in male and female patients without an ITA graft was more than two-fold higher compared to these with single ITAs and more than three-fold higher compared to those with BITA grafting. CONCLUSIONS: Female gender, frequently associated with diabetes mellitus, presents a predictor for increased mortality in CABG. A discrimination of women with respect to a restriction of ITA grafting could be confirmed only for bilateral ITAs. The superior results of bilateral ITA grafts are independent of gender.

BACKGROUND: The relative resistance to arteriosclerosis of the internal thoracic artery is clinically valid. The aim of this study was to evaluate the graduation of intima and media fibrosis in ITA parts and to determine the extent of atherosclerosis using immunohistochemical methods related to patients' risk factors. METHODS: 227 distal ITA segments from 144 male and 83 female patients were examined. Mean age was 66.7 ± 9.03 years. HE and Elastica van Gieson staining was performed to detect intima-/mediafibrosis. Population: insulin-dependent diabetes mellitus (idDM; n = 35), non-insulin-dependent diabetes mellitus (nidDM; n = 32), irradiation of the chest due to cancer (n = 27), control group with isolated hyperlipidemia, hypertension, peripheral vascular disease (n = 133). 12 ITA segments of each group were examined immunohistochemically using CD34, CD68, Tenascin, Collagen III, Collagen IV. RESULTS: Histomorphological examinations using HE and Elastica van Gieson stainings showed for idDM-ITAs no fibrosis in 57 %, slight fibrosis in 34 %, medium in 6 %, no severe, for nidDM-ITAs no fibrosis in 63 %, slight 31 %, medium 3 %, severe 3 %, for ITAs after irradiation: no fibrosis in 37 %, slight in 62 %, no medium or severe fibrosis. Compared to the control group there was no statistically significant difference in diabetic ITAs. Immunohistochemical examinations, scored on a 0 - 3 basis with 0 being the lowest (no reaction), 3 the highest (severe reaction), showed mostly no or slight reaction to CD34, CD68, Tenascin, and Collagen III for intima and media, with comparable results for diabetic or “irradiated” ITAs to those of the control group. The most distinct reaction (medium= 2), was detected for Collagen IV, a marker which outlines basement membranes of endothelia and smooth muscle cells of the vessel wall, but without differences between the four groups. No severe reactions were observed. CONCLUSIONS: The relative resistance of ITA to arteriosclerosis could be demonstrated in 227 ITA segments. Immunohistochemistry supports histomorphological findings. The influence of diabetes mellitus and irradiation remains irrelevant.

BACKGROUND: Clopidogrel application before diagnostic or therapeutical percutaneous coronary intervention has become the standard for stent thrombosis prevention. Irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting is necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. METHODS: We retrospectively analyzed 128 patients (operated between January 2000 and September 2002) undergoing urgent or emergent CABG using both ITAs, and compared 64 patients with previous clopidogrel and aspirin application (within 5 days) to 64 patients without clopidogrel. We evaluated chest tube output, re-exploration rate and necessity of blood products, ventilation time and ICU stay. RESULTS: Both groups were comparable in age, gender, number of performed anastomoses (mean 4/patient). Chest tube output (24 h) was higher in the clopidogrel group at 977 ± 628 ml vs. 788 ± 389 ml (p = 0.046), as was re-exploration rate with 7.81 % (5 of 64) vs. 0 % (0 of 64) (p < 0.005). The number of blood products amounted to 2.7 ± 1.9 U in the clopidogrel group vs. 1.9 ± 1.6 U (p = 0.013) for red cells, 0.05 ± 0.9 U vs. 0.03 ± 0.25 (p = 0.0003) for platelets, and 0.5 ± 1.3 U vs. 0.2 ± 1.0 U (p = 0.14) for fresh frozen plasma. Mechanical ventilation time was 11.9 ± 9.7 h vs. 9.6 ± 5.9 h (p = 0.10), ICU stay 32.6 ± 22.1 h vs. 27.8 ± 18.2 h (p = 0.19). CONCLUSIONS: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, re-exploration rate and necessity of blood products, especially platelets. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.

BACKGROUND: The occurrence of severe carotid artery disease in more than 12 % of patients requiring CABG results in a discrepancy concerning the best treatment for both diseases. We reviewed the early outcome of patients with CABG and/or valve replacement and simultaneous carotid endarterectomy (CEA). METHODS: We evaluated retrospectively 244 patients operated simultaneously between 7/94 and 10/2001. 209 patients received CABG; 35 patients CABG and/or valve replacement. Mean age was 68 years. 188 patients were male. We analyzed risk factors, morbidity, incidence of neurological complications and 30 day mortality. RESULTS: Perioperative stroke with hemiplegia occurred in 3.3 % (8 patients). 4 of these patients showed contralateral carotid artery occlusion, 2 contralateral severe stenosis. 2 patients (0.8 %) experienced prolonged reversible ischemic neurological deficit (PRIND), 4 patients (1.6 %) transient ischemic attack (TIA). 30-day lethality was 4.5 %. 3 patients died due to low cardiac output, 6 patients due to extracardial reasons, 2 patients (0.8 %) developed a cerebral death. CONCLUSIONS: Simultaneous CEA and cardiac surgery can be performed with an acceptable risk for neurological complications and mortality. Occlusion of contralateral carotid artery could be identified as an evident predictor for increased neurological complications. Compared to two-stage procedures, combined operations yield a reduction of hospital costs.

BACKGROUND: Superior patency-rate of ITA, especially BITA-grafting to saphenous vein grafts, is conclusive. This study evaluates angiographic findings postoperatively in 663 symptomatic patients receiving one or both ITAs and vein grafts. METHODS: 663 patients (553 male, mean age 62) with CABG operated between 1/94 and 6/02 underwent reangiography due to reappearance of angina or unclear cardiac symptoms. Angiographic data were compared for patency rate of single ITA (n = 379), bilateral ITA (n = 220) or vein grafts. Recatherization was performed after an average of 1000 days (± 766 days). Severe bypass stenosis or occlusion was related to target vessels for all grafts. RESULTS: 2099 Bypasses were performed in 663 patients. Severe stenosis or occlusion was detected in 255 ACB (19.9 %) of 1280 and 93 ITAs of 819 (11.4 %, p < 0.001). Patency was 88.8 % (532) for LITA, 88.2 % (194) for RITA. Target vessels were as follows: LITA: 60 % (358) LAD, 23.5 % (141) CX, RITA: 82 % (180) LAD. Occlusion rate for LITA was as follows: to LAD 7 %, to DIA 8.7 %, to CX 8.5 %. Occlusion rate for RITA as follows: to LAD 6.7 %, to DIA 16.7 %, to CX 0, to RCA 14.3 %. Occlusion rate for ACB was as follows: to LAD 18.7 %, to DIA 12.6 %, to CX 14.1 %, to RCA 16.1 %. Despite symptoms, bypass patency was observed in 412 (62.1 %) of 663 patients. CONCLUSIONS: Superior patency of ITA, especially BITA grafting could be documented angiographically in a negative selected symptomatic population. Graft occlusion was nearly two fold higher in vein grafts. Our surgical strategy, revascularizising RITA with LAD, LITA with circumflex artery results in satisfactory mid-term graft patency.

Acute graft occlusion early postoperatively after coronary artery bypass grafting (CABG) is a rare but dramatic complication, frequently making resuscitation necessary. Emergency reoperation with reanastomosing of the concerning grafts is the normal procedure to restrict the otherwise unavoidable myocardial damage. Mortality in these cases is up to 50%. Due to this unsatisfying situation, we perform since 1995 in such cases an adjuvant intraoperative intracoronary installed fibrinolysis with recombinant tissue type plasminogen activator (rt-PA; alteplase).

Zusammenfassung: Zielsetzung: Die akute Mesenterialischämie ist eine seltene, aber schwerwiegende Komplikation nach herzchirurgischen Eingriffen. Die Inzidenz ist mit 0,2 bis 0,4% niedrig, die Mortalitätsrate liegt jedoch zwischen 70 und 100%. Methoden: Von 10/92 bis 12/96 wurden in der Abteilung für Cardiovascularchirurgie in München-Bogenhausen 4640 Patienten unter dem Einsatz der Herz-Lungen-Maschine operiert: 74,6% koronare Bypass-Operationen, 23,2% Eingriffe an Herzklappen, davon 8,8% in Kombination, sowie 2,2% Sonstige Eingriffe. Die Gesamtletalität (30 Tage) lag bei 3,4%, nach koronaren Bypass-Operationen bei 2,9%. Die Krankenunterlagen dieser 4640 Patienten wurden retrospektiv bezüglich des Auftretens akuter, postoperativer Mesenterialischämien untersucht. Ergebnisse: 11 Patienten (0,24%) entwickelten in der frühpostoperativen Phase nach Bypass-Operation (einmal mit Aortenklappenersatz, einmal mit Carotis-TEA) eine akute Mesenterialischämie (Tag 1 bis 5). Bei allen Patienten stellten sich initial variable abdominelle Symptome ein, zusätzlich zeigte sich eine Leukozytose (19,2±5,6/nl), Azidose (pH 7,26±0,07), Hyperlaktatämie (14,9±13,2 mmol/l), Hyperosmolalität (339±9,0 mosm/kg), progredientes Nierenversagen und schließlich hämodynamische Instabilität. Alle Patienten wurden notfallmäßig laparotomiert. Eine angiographische Darstellung der Mesenterialgefäße erfolgte bei 6 Patienten, die sich noch in einem klinisch stabilen Zustand befanden, wobei jeweils hochgradige pathologische Befunde an den Mesenterialgefäßen festgestellt werden konnten. Andere diagnostische Verfahren waren nicht aussagekräftig. Während des Ersteingriffs handelte es sich in sechs Fällen (55%) um eine ausgedehnte Darmnekrose, fünf Patienten zeigten zu diesem Zeitpunkt einen makroskopisch unauffälligen Darm. Drei dieser fünf Patienten entwickelten im weiteren Verlauf ausgedehnte Darmnekrosen. Bei einem Patienten konnte intraoperativ durch mechanische und medikamentöse Maßnahmen die Darmfunktion wiederhergestellt werden. Bei einem Patienten gelang die Rekanalisation eines proximalen Verschlusses der A. mesenterica superior während der Notfallangiographie. Diese beiden Patienten waren die einzigen Überlebenden der untersuchten Gruppe, neun von elf Patienten (81,8%) starben zwischen dem ersten und sechsten postoperativen Tag nach Laparotomie im Multiorganversagen. Da die histopathologischen Ergebnisse in 63,6% eine nichtocclusive, periphere Darmischämie und in nur 36,4% eine occlusive Darmischämie zeigten, muß ursächlich in der Mehrzahl von einer Mikrozirkulationsstörung bei ausgeprägter Vasokonstriktion im Splanchnikusgebiet und erhöhter Blutviskosität ausgegangen werden. Prädisponierend für eine Mesenterialischämie sind: arteriosklerotische Patienten nach koronarer Bypassoperation (100%), hohes Alter >70 (90,8%) und vor allem eine hyperosmotische Dehydratation (100%). Schlußfolgerung: Die Mesenterialischämie nach herzchirurgischen Eingriffen ist eine schwerwiegende Komplikation mit extrem hoher Mortalitätsrate und stellt sich entweder als occlusive, proximale oder als nichtocclusive, periphere Erkrankung dar. Vorwiegend gefährdet sind alte, dehydrierte Patienten mit generalisierter Arteriosklerose. Da die Mesenterialischämie häufig beim anästhesierten Patienten beginnt, ist die frühzeitige Diagnosestellung erschwert. Mit dem Auftreten typischer Symptome müssen ungeachtet der oft kritischen klinischen Situation der Patienten unverzüglich Angiographie mit möglicher PTA und intraarteriellen Vasodilatantien sowie Laparotomie eingeleitet werden. Wenn bereits Darmnekrosen aufgetreten sind, ist die Prognose trotz ausgedehnter Resektion sehr schlecht. Eine Prävention kann erreicht werden, indem eine ausgeprägte Dehydrierung von Risikopatienten vermieden wird.