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An improved technique of free internal mammary artery (IMA) to ascending aorta anastomosis for coronary bypass is described. A small patch vein with a suitable side branch or branches is interposed, connecting the proximal end of a detached IMA to the ascending aorta. A single or double free IMA alone or in combination with an additional saphenous vein graft was performed in 77 patients. A total of 125 free IMA grafts were done. The hospital mortality was 2-7% and late mortality 1-4%. Seventy-one of the 74 surviving patients had no angina and returned to a normal life. Postoperative coronary arteriography in 65 patients showed a patency rate of 96%. On year's experience with this technique is very encouraging. However, prolonged follow-up is necessary to determine if free IMA, as used by us, will increase the long-term patency rate. [ABSTRACT FROM PUBLISHER]

Life-table analysis consecutive cases of isolated coronary bypass surgery at the Buffalo Hospital between 1973 and 1977 showed an estimated survival of 94 per cent at five years, equal to that of an age- and sex-matched group of the US population. Subsets of these patients divided according to sex, age, number of vessels narrowed, number of segments grafted, history of myocardial infarction, ejection fraction, and presence of unstable angina have estimated survivals not statistically less in any of these subsets than that of matched cohorts of the general population. [ABSTRACT FROM PUBLISHER]

Myocardium reperfusion following coronary artery bypass grafting (CABG) may result in "reperfusion injury" by free radical generations. Since desferrioxamine administration attenuates this syndrome, non-transferrin-bound-iron (NTBI) released into the perfusing medium during CABG was implicated as a catalyst for oxygen radical formation. From 13 patients with "redo" CABG, specimens were collected from the coronary sinus (influx) and the aortic vent (efflux) after each distal coronary anastomosis. Specimens were subjected to sieving chromatography, and fractions were analyzed for total iron and NTBI using atomic absorption spectrometry (AAS). A statistically significant increase in NTBI was measured in influx (p = 0.002) and efflux samples (p = 0.023) collected after each graft. The combined amount of NTBI measured in these specimen was proportional to the CK-MB increase measured in the patients' sera on the day of surgery and the subsequent day. NTBI which accumulated in the circulatory bypass fluid during CABG may catalyze the generation of free radicals in the myocardium when body temperature is restored. This may aggravate myocardial damage as reflected by a post-surgical increase in CK-MB concentrations. Studies are in progress to develop new methods for the removal of NTBI during cardiac surgery. Tissue injury occurs with reperfusion during ischemia. This has been attributed to oxygen-derived free radicals that are generated by substances released from hypoxic areas (Kloner, Przyklenk et al., 1989; McCord, 1998). Reperfusion injury, i.e. the "reperfusion syndrome," occurs after coronary artery bypass grafting (CABG) when the ischemic myocardium is again provided with a supply of blood. Its most serious manifestations are arrhythmia and myocardial stunning (Ar"Rajab, Dawidson et al., 1996; Ferrari, Ceconi et al, 1996). The role of iron in reperfusion injury has been implicated by indirect evidence: during the reperfusion syndrome, the binding of iron with the chelator desferrioxamine (Ambrosio, Zweier et al., 1987; Bel, Martinod et al., 1996), or the administration of exogenous apo-transferrin, improved cardiac contractility and delayed manifestations of cardiac injury (Tiede, Sareen et al., 1990). Iron, as a transition metal, is able to catalyze free radical formation when released into the circulation from endogenous stores as non-transferrin-bound-iron (NTBI). This iron may be bound to small proteins or inorganic ligands (Halliwell and Gutteridge, 1984; Pollock and Campana, 1980; Zweier, 1992). A method for the measurement of NTBI was recently developed (Ambrus, Stadler et al., 1999). The purpose of this study was to explore whether a correlation exists among (a) the amount of NTBI released during CABG surgery, (b) the length of time of myocardial ischemia, and (c) the myocardial damage that occurs during cardiopulmonary bypass.

Background: Coronary artery bypass grafting (CABG) was performed on patients with cardiopulmonary bypass (CPB group) or without CPB (non-CPB group). A series of CABG patients, performed between January 1, 1995 and September 30, 1997 is included., Methods: Data were collected and analyzed as determined by the New York State Department of Health. Preoperative comorbidity, postoperative morbidity and mortality were compared. There were 2869 patients in the CPB group and 505 patients in the non-CPB group., Results: Demographics of the two groups were similar but preoperative risk factors were more common in patients undergoing CABG without CPB. Of the non-CPB patients, 31.9% had reoperations as compared to 8.5% in CPB patients (p = 0.00005). The presence of an extensively calcified aorta was more common in the non-CPB patients (5.9% vs. 2.8%, p = 0.0002). Immune deficiency was also more common in the non-CPB group (p = 0.001). Risk-adjusted mortality was similar in the two groups while major complications were much less common when CPB was not utilized. In CPB patients only 84.3% avoided major complications, while among non-CPB patients 90.1% were complication-free (p = 0.0008)., Conclusions: CABG without CPB is an attractive method of surgical revascularization. Increasing age and preoperative comorbidity in patients referred for CABG dictate changes in surgical strategy, of which avoidance of CPB appears most beneficial.

The right gastroepiploic artery (RGEA) has been utilized as the bypass conduit on the inferior surface of the heart with a minimally invasive approach. Fourteen patients had reoperative coronary bypass surgery for severely symptomatic single-vessel disease of the right coronary artery. All surgeries were performed since May 1996. A small mid-line incision including splitting of the lower sternum gave excellent exposure. The inferior surface of the heart was dissected to expose and stabilize the target vessel. The heart rate was controlled with a diltiazem drip. Cardiopulmonary bypass was not necessary in any case. The right coronary artery was bypassed in three patients, the posterior descending artery branch in ten patients, and the terminal circumflex of the left coronary artery in one. After grafting, patency of the anastomosis was demonstrated by Doppler echocardiogram. Two patients had left anterior descending artery (LAD) grafts with LIMA (left mammary artery) and RGEA grafts performed simultaneously with two port access incisions. No patient had perioperative mortality or complications. No patient had recurrent angina. Doppler color echocardiographic imaging studies before discharge confirmed patency of the graft in 13 of 14 cases. In one case, the gastroepiploic artery could not be visualized. Angiographic visualization was positive in seven cases; seven patients were not studied yet. The gastroepiploic artery is an excellent conduit for vascularization of the inferior aspect of the heart. The operation can be done with a minimally invasive technique and without the use of cardiopulmonary bypass. This approach seems especially applicable in selective reoperative cases.

The development of implantable defibrillators with single lead systems has necessitated the need for larger transvenous electrodes. This article describes a modified Seldinger technique that can be used when the cephalic vein is too small to allow passage of these larger leads. When successful, the procedure eliminates the need for direct needle cannulation of the subclavian vein and the accompanying risk of pneumothorax.

Background: To evaluate the efficacy of warm versus cold and antegrade versus retrograde cardioplegia, 163 patients were randomized in sequence in three groups and underwent isolated coronary artery bypasses (mean, 4 grafts/patients) alternating in sequence., Methods and Results: The demographic profiles were identical. Cold crystalloid cardioplegia (group 1) was delivered through the aortic root intermittently. The warm retrograde (group 2) was started antegrade with high potassium solution until the heart stopped. It was continued with retrograde coronary sinus perfusion, 100 mL/min of warm blood. Cold retrograde blood cardioplegia (4:1) (group 3) was started antegrade and continued retrograde through the coronary sinus. The heart temperature was kept at 10 degrees to 15 degrees C. Patients were evaluated intraoperatively and postoperatively for (1) supraventricular tachycardia, (2) ECG changes, (3) lactate dehydrogenase and total CPK and isoenzyme (MB) studies, and (4) hemodynamic studies in the intensive care unit. Warm retrograde and cold retrograde patients had sampling of the ascending aorta (antegrade) and the coronary sinus (retrograde) measuring pH, A-VO2 differences, and CK enzyme leak., Results: The incidence of supraventricular tachycardia was 29% in group 2, 22% in group 1, 18% in group 3; not significant (NS). CPK isoenzyme MB fraction showed identical levels (NS). The warm heart consumed 1.3 to 1.6 mL O2/100 mL flow, while the cold group 3 showed 0.5 to 0.6 mL O2/100 mL flow (P < .001). Cold crystalloid cardioplegia (group 1) was similar to group 3 (0.3 mL O2/100 mL). All three groups were similar hemodynamically (cardiac output, cardiac index, left ventricular stroke work index). Two of 163 patients died in group 2. Four sustained stroke, three in group 2, one with a fatal outcome., Conclusions: Continuous warm cardioplegia (group 2) did not provide better myocardial protection despite that no CK-MB isoenzyme leak was demonstrated intraoperatively. Intermittent cold crystalloid cardioplegia and cold retrograde provided a clearer operative field and motionless heart. As long as O2 was adequately supplied, under 90 minutes' cross-clamp time, cold crystalloid cardioplegia and cold retrograde blood cardioplegia is safe under hypothermic conditions, whereas warm cardioplegia requires continuous uninterrupted technique with oxygen delivery.

A 70-year-old woman presented with anular and progressive intramyocardial calcification within a five-year period. She had become increasingly symptomatic with mitral regurgitation and coronary insufficiency during the same period. The subvalvular (mitral) calcified intramyocardial mass was found to be "grumous atherosclerosis." This was obliterated while the mitral valve was replaced with a prosthetic valve and the coronary arteries were bypassed x3. She is surviving and well four years postoperatively.

Surgical management of patients with concomitant critical cardiac disease and resectable lung lesions is controversial. During a 7-year period (1982 to 1988), 21 patients underwent combined cardiac and pulmonary operations. Patients had cardiac symptoms only; the lung lesions were found on preoperative chest roentgenograms. The pathological diagnosis was established in only 2 of the patients before operation. All underwent concurrent pulmonary resection during cardiac operations requiring extracorporeal circulation. The pulmonary operations included 17 wedge resections and four lobectomies. The final diagnoses in 8 patients with stage I non-small cell lung cancer included epidermoid carcinoma (4), adenocarcinoma (3), and bronchoalveolar carcinoma (1). Postoperatively, 1 patient required a permanent pacemaker and 1 patient died. The actuarial survival at 5 years for all patients who underwent combined procedures was 95%. The 5-year survival for the 8 patients with lung cancer was 88% compared with 100% for those with benign pulmonary pathology (p = 0.172). This experience suggests that combining pulmonary resection with cardiac operations is safe and offers a favorable prognosis to a select group of patients.

A 32-year-old man was seen with shortness of breath and increasing fatigue. Echocardiography revealed an intracavitary mass occupying the entire left atrium. The lesion was resected using cardiopulmonary bypass and found to be a large malignant melanoma. This case represents the rare occasion in which antemortem diagnosis of malignant melanoma within left atrium permitted successful palliative surgical resection. The patient is alive and active 6 months after operation.

Complications following open chest massage in patients with porcine xenografts in the mitral location have not been previously described. The authors report a case of cardiac resuscitation following mitral valve replacement with a stented porcine valve. The patient died following brief closed chest, and then, prolonged open chest, cardiac massage. Autopsy showed laceration of the left ventricle by the prosthetic valve stents. Physicians involved in the postoperative care of patients with stented prosthetic valves should be aware of this complication and should exercise caution when applying manual compression in the region of the posterolateral base of the heart.

Metabolic functions of the lung were examined in sixty patients undergoing coronary artery bypass surgery employing a method to separate right and left heart flow during surgery. Six study groups were employed to investigate the activity of normal serum electrolytes, minerals, enzymes and vasoactive prostanoids as they pass through the pulmonary vasculature. Various sample sites were employed to represent isolated segments of the vascular tree: pump (systemic) and right atrium (myocardium), aortic (bronchial flow). LDH, Ca++, phosphate and SGOT were documented to vary with passage through the pulmonary circulation while alkaline phosphatase, bilirubin, creatinine, urate, cholesterol, albumin and BUN remained essentially unchanged. Bronchial flow was calculated and directly related to temperature and pump flow with an average range of 15 ml/min +/- 6 ml/min. The stress of surgery produced elevated PGE2 in bronchial flow and urine that caused reproducible hypotension when rapidly reinfused into the patient. PGE2 production, though decreased with Indomethacin block, could be rapidly reversed with the stress of surgery.

Perioperative and late follow-up hemodynamic cardiovascular studies to assess the effects of direct myocardial revascularization on cardiac function objectively have been completed on 51 patients. Analysis of the data delineated three distinct groups basedon the patterns of their early postoperative recovery. Group I patients (12) had a hyperdynamic cardiovascular response to operation and returned to a normal physiological range of cardiac function within 24 hours. Group II patients (24) initially had moderate to severe myocardial decompensation postoperatively but responded to inotropic support and moved into the normal physiological range within 24 to 48 hours. Group III patients (15) had severe, prolonged myocardial decompensation with little response to inotropic support. There were no early deaths in Group I, 1 early iatrogenic death in Group II, and 2 deaths from sepsis, 1 in Group I and 1 in Group II. All 7 cardiogenic deaths occurred in Group III patients. Late follow-up studies 4 to 23 months postoperatively have been completed on 29 patients. These showed cardiovascular stability in the mean values in Groups I and II. Significant improvement in mean cardiac function was seen in surviving Group III patients.

A simple technique for inducing intracavitary hypothermic cardioplegia and decompressing the left heart through the ascending aorta is presented. The technique is based on siphon drainage, which eliminates the dangers of air embolism.

Nine patients (seven men and two women) were studied while undergoing coronary artery bypass on cardiopulmonary bypass. Selective bronchial flow samples were obtained and analyzed for prostaglandin E2 levels, and the hemodynamic effects of this vasodilator were studied. Bronchial flow collection and measurements were performed during hypothermic cardioplegic arrest while the peripheral anastomosis was being completed, as described previously. This collected sample was reinfused abruptly to the pump circuit, but samples were also analyzed for specific radioimmunoassay antiserum for prostaglandin E2 levels. Urine levels were obtained both with and without indomethacin block. All nine patients were studied for the hemodynamic effects of rapidly reinfused bronchial flow. A 34% +/- 8.8% mean drop of blood pressure and peripheral vascular resistance were recorded (p less than 0.002). Three study groups were established: In Group I, serum prostaglandin assay was performed on six patients. Prostaglandin E2 levels showed an average of increase of 159% compared to the baseline (p less than 0.02). In Group II, urine prostaglandin was measured. Nine assays were performed on six patients. Analysis of the total urine production while on cardiopulmonary bypass showed an average increase in prostaglandin E2 of 300% (p less than 0.02). In Group III, combined serum and urine prostaglandin levels were measured in three patients before and after indomethacin block (50 mg four times a day for 48 hours before the operation). All of these patients demonstrated the same hypotensive phenomena with reinfusion of the bronchial flow. The urinary prostaglandin E2 output and serum prostaglandin E2 levels in bronchial flow were elevated. Overall, this group manifested a 50% reduction in prostaglandin E2 production over baseline values with indomethacin block (p less than 0.02) and a 300% increase in production during cardiopulmonary bypass (p less than 0.02). Our data suggest that significant amounts of prostaglandin E2 are released in the lung during the stress of cardiac operations. Rapid reinfusion of bronchial flow is responsible for hypotension during cardiopulmonary bypass. Pretreatment with indomethacin will not completely block prostaglandin E2 release in the lung during stress.

This study determines if prolonged aortic crossclamp time (ACC) with the use of cold potassium cardioplegia during elective cardiac valve replacement contributed to the risk of operative mortality in 225 patients. In Group I (143 patients), the ACC was less than 120 minutes (mean 86) and in Group II (82 patients), it was greater than 120 minutes (mean 146). The preoperative variables showed that Group II contained more severely ill patients who were undergoing more complex operations than in Group I. The operative mortality rate was 7% in Group I and 10% in Group II (p = not significant). Postoperative inotropic support was required in 13% of Group I and 30% of Group II patients (p less than 0.005). Operative mortality in patients in New York Heart Association (NYHA) functional class I and II was 0 and in patients in classes III and IV it was 13% (p less than 0.00008). Five percent of patients in NYHA classes I and II and 32% in classes III and IV required inotropic support (p less than 0.000005). The actuarial survival at 60 months was 88 +/- 3% for Group I and 77 +/- 7% for Group II (NS). For the NYHA class I and II patients, however, it was significantly better (98 +/- 2%) than class III and IV patients (75 +/- 5%) (p less than 0.0001). Analysis by logistic equation revealed that the NYHA functional classes III and IV were significant incremental risk factors for probability of in-hospital mortality (p less than 0.0001) but not the ACC time (p greater than 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Creatine kinase BB isoenzyme (CK-BB) was detected intraoperatively in 22 of 25 patients undergoing aortocoronary bypass surgery, both in the coronary sinus and in the mixed venous blood. In a group of 10 patients in whom selective intracavitary profound hypothermic arrest was used, CK-BB values were lower than in another group of 10 patients, in whom controlled ventricular fibrillation with moderate total body hypothermia was instituted. This latter group also had higher levels of CK-MB. Patients who developed acute myocardial infarction immediately prior to or during the surgical intervention had the highest CK-BB values. This enzyme appeared as early as 15 minutes after the institution of cardiopulmonary bypass and disappeared within 6 hours. It is considered that part of the BB isoenzyme in serum of patients undergoing heart surgery is of myocardial origin.

The lungs usually deteriorate earlier than the heart in the autoperfused heart-lung preservation technique for transplantation; however, precise lung function during preservation has not yet been examined. The present study evaluated the physiologic changes in the autoperfused heart-lung preparation. Four dogs were tested with a conventional model, however, it was difficult to measure physiologic changes in the lungs. Seven preparations therefore were studied with a modified model in which the preload was kept constant. Stable hemodynamics could then be maintained throughout the experiment. Although pH and PaCO2 could be kept within normal range during preservation by adjusting the ventilator rate, PaO2 during 100% oxygen ventilation decreased significantly after 6 hours. Pulmonary vascular resistance increased transiently after the harvest; thereafter it normalized and remained constant for several hours but again increased markedly after 8 hours. Pulmonary compliance decreased after 7 hours. Complement activation occurred during preservation. There was a significant transpulmonary leukosequestration in the earlier phase of preservation. Platelet aggregation appeared to occur simultaneously, but counts recovered to some extent. In conclusion, autoperfused heart-lung preparation showed good viability up to 5 hours by present techniques. Lung deterioration is multifactorial and includes complement activation, trapping of leukocytes, and platelet aggregation.