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Background . Respiratory complications after successful coronary artery bypass grafting influence the immediate recovery of a patient; however, whether they influence the longevity of a patient is largely unknown. The aim of this study was to examine the effects of preoperative pulmonary risk factors in younger patients and older patients on outcome after coronary artery bypass grafting. Methods . A retrospective chart review was performed on 939 patients who underwent primary coronary artery bypass grafting between July 1987 and November 1996. For better comparison, they were arbitrarily divided by age into two groups: group 1, less than 70 years old (n = 710), and group 2, 70 years old or older (n = 229). The variables collected for each patient included history of chronic obstructive pulmonary disease, active smoking, forced expiratory volume, and ventilatory support for more than 48 hours. These variables were compared with postoperative length of stay in the intensive care unit, length of stay in the hospital, and the midterm survival up to 5 years. The data were analyzed by the use of univariate/multivariate log-rank tests and the method of Kaplan-Meier survival estimates. Results . The presence of chronic obstructive pulmonary disease was associated with increased length of stay in the intensive care unit and in the hospital for both groups. Preoperative forced expiratory volume in 1 second, significantly affected length of stay in the hospital only in the patients less than 70 years old ( p = 0.0001). Delayed extubation beyond 48 hours of ventilatory support resulted in prolonged length of stay in the intensive care unit and in the hospital for patients less than 70 years old ( p = 0.0001, p = 0.0001, respectively) and patients 70 years old or older ( p = 0.0001, p = 0.0001, respectively). The 5-year survival after coronary artery bypass grafting for both groups was significantly influenced by the level of preoperative forced expiratory volume in 1 second ( p = 0.0004, p = 0.0282, respectively). Conclusions . Patients with chronic obstructive pulmonary disease, irrespective of age, stay in the intensive care unit and in the hospital longer after coronary artery bypass grafting. In addition, preoperative forced expiratory volume in 1 second is a significant predictor of 5-year survival in the young and aged individuals undergoing coronary artery bypass grafting.

Background. Despite the steady increase in the number of elderly patients undergoing coronary artery bypass grafting (CABG), skepticism still exists as to whether this operation is justified in older people with a reduced life expectancy. The purpose of this study was to examine the effects of increasing age on outcome after CABG. Methods. A retrospective chart review was performed on 1,689 consecutive veterans of the United States Armed Forces undergoing isolated primary CABG from January 1972 through December 1994. For better comparison, they were arbitrarily divided by age into three groups: group I, 50 years of age or less (n = 213), group II, between 51 and 70 years of age (n = 1,258), and group III, more than 70 years of age (n = 218). Long-term survival for each group was compared to that of their age-matched population derived from Wisconsin life tables. Results. The preoperative ejection fraction was comparable in all three groups ( p = 0.114). The patients older than 70 years of age had received more grafts per operation than the patients 50 years of age and younger (3.7 versus 3.3) ( p = 0.0001). Although the aortic cross-clamp time was prolonged with advanced age ( p = 0.0002), the cardiopulmonary perfusion time was shortest in elderly patients ( p = 0.0001). The early (30-day) mortality for the entire study population was 1.3%. There was a linear correlation between increasing age and early (30-day) mortality: group I, 0.5% (1/213); group II, 1.0% (13/1,258); and group III, 3.2% (7/218). The overall 10-year actuarial survival for all patients was 67%. The 10-year survival was diminished with increasing age ( p = 0.0001): 74% for group I, 68% for group II, and 47% for group III. Comparative analysis of the three groups with their age-matched counterparts demonstrated an age-related survival after CABG. In group I, reduced survival was evident 4 years after the CABG: the 10-year survival in group I was 74.2%, and the survival of their age-matched population was 93.4% (confidence interval, 67% to 81.9%). In group II a survival difference was obvious 8 years after CABG: 10-year survival of 67.5% versus 75.1% in their age-matched population (confidence interval, 64.8% to 71.6%). In the elderly group of patients, no survival difference was noted: 10-year survival of 42.7% versus 45.9% of the age-matched population (confidence interval, 29.8% to 64.6%). Conclusions. An acceptable early mortality and longterm survival equal to those seen for an age-matched elderly population are sound outcome measures that support the justification of CABG in older patients irrespective of age.

Large, organized right ventricular thrombi are rare. This report describes a 51 year old man with a history of recurrent pulmonary emboli treated with inferior vena cava ligation who subsequently developed multiple mobile calcified thrombi in the right ventricle. He was treated successfully by surgical resection. Unusual clinical presentation on admission consisted of a two component friction rub secondary to calcified masses rubbing against each other in systole and diastole. Cardiac catheterization showed a constrictive-restrictive pattern that persisted after surgery. The role of noninvasive studies in the diagnosis and long-term follow-up of the patient is emphasized.

A computerized fluoroscopy system has been developed on the basis of real-time digital processing of x-ray transmission data from traditional image-intensified fluoroscopy equipment. High-quality visualization of any part of the arterial system is obtained following intravenous injection of 0.5 to 0.75 ml/kg of iodinated contrast materials. This report describes the use of this technique to evaluate the aortic arch, left ventricular function, and coronary artery bypass graft patency. Fifty intravenous studies were performed in 25 patients. Among 20 patients with coronary artery bypass grafts, computerized fluoroscopy correctly identified 11 of 15 patent grafts and 11 of 11 occluded grafts as confirmed by standard coronary arteriography in 11 of these patients. Unlike computerized tomography, our technique gives a longitudinal view of the bypass graft much like direct coronary angiography. Aortic arch studies included demonstration of a right aortic arch with a small left subclavian artery, a coarctation, and a normal aortic arch in a trauma patient with a wide mediastinum. Segmental wall motion abnormalities were clearly identified by a modification of the technique which produces a negative outline on the ventriculogram in dyskinetic segments. Ejection fractions may be calculated by determining the amount of iodine in the ventricle in systole and diastole. This technique may also be used to evaluate carotid disease and peripheral vascular disease in patients undergoing coronary artery bypass procedures. Computerized fluoroscopy, therefore, allows evaluation of the entire cardiovascular system by the relatively noninvasive technique of intravenous angiography.

A retrospective analysis of 38 patients undergoing cardiac catheterization with the diagnoses of hypothyroidism and chest pain revealed 23 to be euthyroid while receiving replacement therapy and 15 to be hypothyroid. Cardiac index was significantly reduced (p less than 0.01) in hypothyroid and euthyroid patients with thyroxine values between 4 and 7 micrograms/dl (2.8 +/- 0.7 and 3.0 +/- 0.9 L/min/m2, respectively), compared to euthyroid patients with thyroxine values greater than 7 micrograms/dl with or without coronary artery disease (4.0 +/- 1.2 and 4.0 +/- 0.7 L/min/m2, respectively). Ten hypothyroid patients underwent coronary artery bypass. There were no deaths, and only one patient required prolonged postoperative intubation. With a mean follow-up of 36 months, there have been no myocardial infarctions and one late death, which occurred at 7 years secondary to stroke. We conclude that preoperative thyroid replacement therapy is theoretically dangerous and may not significantly improve hemodynamics until full replacement is achieved. Coronary bypass grafting can be performed safely despite hypothyroidism with excellent early results.

Pericardiocentesis with catheter insertion and drainage is widely used in management of large pericardial effusions and cardiac tamponade. Two potential problems with an indwelling pericardial catheter system are catheter blockage and infection. We have utilized slow infusion of heparinized saline solution (3 ml/hr) via a continuous flush device to maintain catheter patency for up to seven days (mean 3.6) in 16 patients. Pericardial effusions were secondary to malignancy, uremia, and cardiac surgery. This article describes practical aspects of the technique. Most pericardial effusions can be successfully treated with pericardiocentesis and catheter drainage, provided the drainage is continued reliably and safely for several days. Surgical treatment such as subxiphoid pericardiostomy or partial pericardiectomy should be reserved for loculated effusions, clotted blood, subacute effusive-constrictive pericarditis, or significant recurrences after initial drainage.

Fifty-two patients underwent replacement of the aortic valve with a homograft and were followed for two to four and one-half years. There was no intraoperative mortality; 3 patients died in the immediate postoperative period and 7 patients died after discharge from the hospital. The results are very favorable when compared with the results in patients who have undergone replacement with aortic valve prostheses and have been followed at least two years. Patients with aortic homografts have been spared the problems of anticoagulants, and no emboli have been recognized. Eighteen of 42 survivors now have diastolic murmurs that are not hemodynamically significant. Neither diastolic murmurs that have been present continually nor those that have appeared late have been associated with deterioration of the patient's state, and all patients remain normally active with very few taking any medication. The homografts have proved to be excellent aortic valve replacements, and their continued use is justified.

A simple and effective technique is described for monitoring arterial pressures and blood gases using the ulnar artery at the wrist. This method can be used for up to five to seven days postoperatively and is admirably suited to adult patients. No permanent vascular or neurological damage to the hand has been observed in more than 300 patients in whom this method was used. A few patients have noted transient paresthesia following use of this technique. In 1 patient this persisted for three months postoperatively, but it is now resolving.

A new surgical technique using perfusion of the circumflex coronary artery with retrograde blood flow of the internal mammary artery (IMA) is described. This project was undertaken because the IMA is uniquely well supplied with blood: proximally through its attachment to the subclavian artery, along the sternum by the intercostal arteries to the aorta, and distally from the iliac artery by the epigastric and musculophrenic arteries. In this experimental study, the IMA in 16 dogs was ligated and divided at the subclavian artery, then dissected free down along the sternum to obtain sufficient length. The large subclavian end was then anastomosed to the circumflex coronary artery using a metal cannula technique to perfuse the circumflex bed while the anastomosis was being done. In all 16 dogs, the retrograde flow of the IMA was adequate to maintain the circumflex bed. It is postulated that this technique may have some limited use in man.

Results of long-term follow-up of an early cohort of patients receiving aortic valve homografts for aortic stenosis and aortic insufficiency are presented. All patients were operated upon by a single surgeon from 1966 to 1971. Eighty-three patients underwent insertion of 85 homograft aortic valves. Homografts were sterilized with either betapropiolactone (39 valves) or gamma irradiation (41 valves) and were inserted following storage in nutrient medium (16 valves) or after cryopreservation (51 valves). All homograft valves were sutured in the subcoronary position using a freehand technique. There was a 55 percent 15-year actuarial patient survival and a 16 percent 15-year actuarial homograft survival in this cohort. Homograft valve failure occurred gradually allowing the patients to be observed until they developed hemodynamic compromise at which time elective valve replacement was performed.

• Survival data were reviewed for 3330 open cardiac procedures from 1975 through 1984 at the William S. Middleton Memorial Veterans Hospital, Madison, Wis, and the University of Wisconsin Hospitals and Clinics, Madison. Respective operative survivals were 98.6% and 98.7% for myocardial revascularizations with vein graft or internal mammary artery (CABG), 96.2% and 96.8% for CABG reoperation, 97.8% and 95.9% for aortic valve replacement, 96.3% and 90.3% for aortic valve replacement plus CABG, 100.0% and 94.9% for mitral valve replacement, and 100.0% and 82.9% for mitral valve replacement plus CABG. There were no significant differences in six-year survival curves between hospitals despite threefold differences in average annual caseload (88 vs 294). This suggests that residency-directed cardiac surgery programs can function equally as well at a Veterans Administration hospital as at an affiliated university hospital. ( Arch Surg 1988;123:439-443)

The purpose of this study was to determine if chest tubes that are not milked or stripped occlude more frequently than milked or stripped tubes, and if the amount of drainage varies according to the treatment of the tubes. Following coronary artery bypass graft procedures, 49 male subjects had their chest tubes milked every 2 hours, had them stripped every 2 hours, or served as controls (i.e., their tubes were neither milked nor stripped). An analysis of variance was applied to the results. There was no significant difference in total drainage volume, hourly zero drainage, heart rate, or occurrence of arrhythmias among the three groups of subjects. Four to 16 hours postoperatively, a significantly higher volume of drainage occurred in the subjects whose chest tubes had been stripped. Stripping is particularly discouraged during this interval. The chest tubes remained patent with or without milking or stripping. We conclude that neither milking nor stripping is necessary for the proper care of chest tubes. We recommend that tubes be positioned such that they promote continuous drainage.

Coronary angiography defines the location and size of obstructive lesions, but does not assess their physiological significance. To assess a new method to measure the blood-flow waveform, reversed saphenous vein grafts from the left subclavian artery to the left anterior descending coronary artery were placed in five mongrel dogs. Contrast material was injected selectively into the vein graft while obtaining fluoroscopic images from AP and 45° LAO projections. Blood flow was measured under baseline, low-flow, and hyperemic conditions using an electromagnetic flow probe (EM). Seventeen radiographic determinations of mean blood flow (range 18–130 ml/min) were linearly correlated to simultaneous EM measurements ( r = 0.91 and 0.88, respectively). Contrast material injections changed EM flow measurements by an average of 35%, which though large, is less than with other radiographic methods. The computed blood-flow waveforms had a time resolution of 1 30 sec and were in good agreement with EM waveforms measured simultaneously. Clinical application of this radiographic method for determining the blood-flow waveform may allow early prediction of coronary artery bypass graft closure.

• In the ectotherms, or cold-blooded animals, carbon dioxide pressure decreases (Pco 2 ) and pH increases as body temperature falls. This tends to increase coronary blood flow and prevent fibrillation. This concept was investigated in 181 consecutive patients undergoing open heart surgery of all types. In 121 cases, endothermic (warm-blooded) temperaturecorrected normal values of pH, Pco 2 , and oxygen pressure were maintained during extracorporeal circulation as the perfusate temperature was lowered to 24 °C prior to aortic crossclamping and administration of blood cardioplegia solution. In 49 patients (40%), ventricular fibrillation occurred prior to cross-clamping. In the other 60 consecutive cases, in which the ectothermic principle of cooling was applied, the Pco 2 was allowed to decrease from 50 to 40 mm Hg and the nontemperature-corrected pH rose from 7.28 to 7.42. Fibrillation occurred in only 12 (20%) of these 60 patients. ( Arch Surg 1986;121:303-304)