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Multiple factors affect the systolic and diastolic components of pulmonary venous flow. It has been suggested that left ventricular function might influence the effects of filling pressures on indexes of pulmonary venous flow. The present study was designed to evaluate the effect of the pulmonary wedge pressures, left ventricular function, and cardiac output on the pulmonary vein flow pattern. Forty-five patients undergoing cardiac surgery were included in this study. Pulmonary venous flow and mitral flow variables were obtained by transesophageal echocardiography with hemodynamic variables obtained simultaneously. In the total group, there was no consistent relation between the pulmonary venous flow or the mitral flow parameters and the capillary wedge pressures. When patients were grouped according to normal (>2.2 L/min/m2) or low (

Purpose: The purpose of this study was to assess the incidence of and predictors for vascular complications in patients who required perioperative intraaortic balloon pump (IABP) support. Methods: Data from 580 patients collected with a retrospective review were statistically analyzed with 25 perioperative parameters, and significant variables were evaluated with multivariate analysis. These data were also statistically compared with data from a 1983 study from our institution. Results: Vascular complications occurred in 72 patients (12.4%). The three aortic perforations were fatal. Ipsilateral leg ischemia occurred in 69 patients. Of these, ischemia was resolved in 82% of patients by IABP removal (21), thrombectomy (21), vascular repair (13), fasciotomy (2), or without intervention (2). Six patients died with the intraaortic balloon in place. Four patients required amputation for ischemia, but all survived. Conclusions: Vascular complications were not predictive of operative death (p = 0.26). Risk analyses with 25 perioperative parameters revealed that history of peripheral vascular disease, female sex, history of smoking, and postoperative insertion were independent predictors of vascular complications. However, most risk for vascular complications cannot be explained by these factors because of a low R 2 value. Compared with the results of our 1983 study, the incidence of IABP-related complications has not changed, but the severity of complications has decreased significantly, and IABP-induced death has decreased significantly. (J VASC SURG 1994;19:81-9.)

From March 1990 through January 1992, 108 patients undergoing myocardial revascularization had one (91) or both (17) inferior epigastric arteries (IEA) used for myocardial revascularization. The internal thoracic artery (ITA) was used bilaterally in 87 patients. Of the 373 distal anastomoses, 210 (56%) were with the ITA, 130 (35%) with the IEA, and 12 (3%) with the gastroepiploic artery. Nineteen patients (18%) received 21 saphenous veins. When compared with the ITA, the IEA demonstrated a longer harvest time (36.5 vs 29.6 min, P0.0001), a shorter usable length (11.9 cm vs 16.5 cm, P0.001), and similar flow (49.7 cc/min vs 48.7 cc/min, P = NS). The operative mortality was 2.8%. Two deaths resulted from low cardiac output and the one remaining death from complications of a cerebral vascular accident. The most common major complication was respiratory insufficiency, which occurred in 11 patients (12%). There were two sternal infections (2%), and two abdominal wound infections (2%), none of which were fatal. The IEA is an acceptable additional arterial conduit. It can be safely employed with one or both ITAs. Short-term and long-term patency must be established before preferential use of this conduit is advised.

The intraaortic balloon pump is usually the first mechanical device inserted for perioperative cardiac failure; however, little current information is available regarding short- and long-term effectiveness. From January 1983 through November 1990, 6856 adult patients underwent cardiac surgical procedures, 580 of whom (8.5%) had an intraaortic balloon inserted preoperatively (107 patients), intraoperatively (419 patients), or postoperatively (54 patients). There were 374 men and 206 women with a mean age of 63.9 years (range 19 to 88). Operations included 376 coronary artery bypass grafts, 100 mitral valve replacements (with or without bypass grafting), 70 aortic valve replacements (with or without bypass grafting), 15 double valve replacements (with or without bypass grafting), and 32 other procedures. There were 72 (12.4%) complications related to the balloon pump, of which 42 necessitated surgical intervention including thrombectomy (21), vascular repair (13), fasciotomy (2), aortic repair (1), and amputation (4). Operative mortality for patients supported by the balloon pump was 44%. Multivariate stepwise analysis of 27 parameters revealed six independent predictors of mortality: preoperative New York Heart Association class, transthoracic intraaortic balloon insertion (both p < 0.0001), preoperative administration of intravenous nitroglycerin, age, female gender, and preoperative balloon insertion (p < 0.001). Balloon-related complications were not predictive of death. Of the 326 hospital survivors, only 34 were lost to follow-up. There were 75 late deaths, the cause of which was cardiac in 41 (55%), noncardiac in 20 (27%), and unknown in 14 (19%). Actuarial survivals at 1, 5, and 9 years are 51%, 42%, and 33%. Of the 217 hospital survivors still alive and contacted, 81% were in class I (114) or II (60). These data demonstrate (1) operative mortality for patients requiring an intraaortic balloon in the perioperative period remains high, (2) perioperative risk factors can be identified, (3) complications related to the balloon pump do not affect survival, (4) operative survivors can achieve prolonged survival with excellent functional results, and (5) consideration for alternative methods of circulatory support is justified.

The role of retrograde coronary sinus cardioplegia in patients undergoing aortic valve replacement for aortic stenosis alone or in combination with myocardial revascularization has not been fully defined. Sixty-three patients undergoing elective aortic valve replacement received cold potassium blood cardioplegic solution via either the aortic root (36 patients) or the coronary sinus (27 patients). The patients were similar with respect to age, degree of aortic stenosis, ventricular function, severity of coronary artery disease, crossclamp time, completeness of revascularization, and mean volume and temperature of the infusion solution. The mean septal temperature and the release of myocardium-specific isoenzyme in the first 2 hours after crossclamp removal was higher in the retrograde group (p horac C ardiovasc S urg 1992;104:130–8)

The internal mammary artery (IMA) is the conduit of choice for myocardial revascularization. From 1972 to 1989, 586 patients received bilateral IMA and supplemental vein grafts. There were 506 men (86%) and 79 women (14%) with a mean age of 55.5 years (range 32-77 years). Unstable angina was present in 138 patients (24%), insulin-requiring diabetes mellitus in 83 (14%) and previous myocardial infarction (MI) in 25 (4%). Preoperative angiography demonstrated triple-vessel disease in 286 patients (49%) and double-vessel disease in the remaining 300 patients (51%). Left main coronary artery disease (stenosis greater than or equal to 50%) was present in 53 (9%). The mean left ventricular score was 7.4 with a range of 5 to 20. The mean number of grafts performed was 3.4 per patient. Hospital mortality was 3.6% (21 patients). Follow-up was done through direct patient contact, via the patient's physician or by telephone contact with the patient themselves or surviving family members. Follow-up was complete in 518 hospital survivors and ranged from 1 month to 17.5 years with a cumulative follow-up of 911 patient years. At 10 and 15 years, respectively, the actuarial freedom from MI was 78% and 72% and freedom from reoperation was 93% and 86%. Actuarial survival at 10 and 15 years was 85% and 70%, respectively. This longitudinal analysis demonstrates that bilateral IMA grafting has a low operative risk. The data suggest that utilization of two IMA grafts yield excellent freedom from recurrent symptoms and provides excellent long-term survival.

Ultrasonic decalcification of the aortic valve was performed in 22 elderly patients with critical aortic stenosis (aortic valve areas less than 0.8 cm2) as an alternative to prosthetic valve replacement. All of the patients had symptoms. The mean New York Heart Association class was 3.3 +/- 0.9. Adequate decalcification with restoration of leaflet mobility was achieved in all patients, including seven with bicuspid aortic valves. Leaflet perforation occurred and was successfully repaired in five patients. Ten patients underwent concomitant myocardial revascularization. There were two operative deaths (9%) and three late deaths. Echocardiograms were obtained preoperatively, postoperatively, and at 6 months. The mean aortic valve area increased significantly from 0.72 +/- 0.17 to 1.42 +/- 0.31 cm2 (p less than 0.001) and the peak gradient decreased from 74 +/- 34 to 25 +/- 13 mm Hg (p less than 0.001). At 6 months the aortic valve area (1.29 +/- 0.48 cm2) and peak gradient (31 +/- 12 mm Hg) continued to be significantly better than the preoperative measurements (p less than 0.001), but the 6-month aortic valve area was slightly decreased and the gradient increased when compared with the immediate postoperative values (p less than 0.02). The prevalence of mild to moderate aortic insufficiency increased from 50% of the patients preoperatively to 87% at 6 months (p less than 0.05). Two patients subsequently required aortic valve replacement for restenosis and aortic insufficiency. Ultrasonic decalcification is effective in relieving aortic stenosis, but subsequent restenosis and insufficiency may limit its application.

From July 1, 1984, through June 30, 1989, after 1,259 open heart operations, 110 patients (8.7%) underwent 162 early reoperations either in the intensive care unit (144 procedures) or in the operating room (26 procedures). Reexploration for bleeding (49 procedures) (3.9%) and intraaortic balloon removal (50 procedures) (4.0%) were the two most common procedures. Ninety percent and 96% of these procedures, respectively, were performed in the intensive care unit. Mediastinal infections occurred in 4 (6.1%) of 66 patients undergoing repeat mediastinal operations for all indications. No infection occurred after reexploration for bleeding nor did mediastinal infection occur after reoperation in the intensive care unit. Postoperative death in these 110 patients was not related to reoperation except possibly in the case of 1 patient (0.9%). Average transit time to and from the operating room for patients returned there for reoperation was 89.7 minutes. Charges for procedures performed in the operating room were at least twice as great as for those performed in the intensive care unit. This experience supports expanded use of reoperation in the intensive care unit, as it is safe, effective, economical, and convenient.

One hundred consecutive patients who had coronary artery bypass grafting using both internal thoracic arteries (ITAs) and saphenous veins, operated on during a 3-year period between 1972 and 1975, have been compared retrospectively with a series of 100 patients operated on during the same period who had one ITA graft along with saphenous vein grafts. The two groups were similar with respect to age, sex, risk factors for coronary artery disease, angina class, extent of coronary artery disease, left ventricular function, number of coronary bypass grafts performed, and completeness of revascularization. Single ITA operative mortality was 2% and double ITA, 9% (p = NS). The mean follow-up of hospital survivors was 14.4 +/- 2.7 years; all but 7 patients had follow-up for at least 10 years. At 13 years, the actuarial patency of the right ITA was 85% and the left ITA, 82%. These data strongly suggest a survival benefit for patients with double ITA grafts among hospital survivors (74% versus 59%; p = 0.05). Patients receiving two ITA grafts had a significant freedom from subsequent myocardial infarction (75% versus 59%, p less than 0.025), recurrent angina pectoris (36% versus 27%, p less than 0.025), and subsequent total ischemic events (32% versus 18%, p less than 0.01). These data also suggest improved freedom from coronary artery interventional therapy (percutaneous transluminal coronary angioplasty and reoperation) when two ITA grafts were used. These results support the use of bilateral internal thoracic artery grafting in selected patients.

The increasing safety of cardiac surgery has led to the frequent referral of octogenarians for operation. Between 1980 and 1989, we reviewed our experience with 103 octogenarians (59 male, 44 female; mean age 82 years) to determine the surgical risk factors and outcome in the elderly population. There were 71 coronary bypasses (CABG), 11 aortic valve replacements (AVR), 11 AVR-CABG, 4 mitral valve replacements (MVR), 3 MVR-CABG and 3 AVR-MVR-CABG. Seventeen patients died during hospitalization (16.5%) including 9 CABG (13%); 1 AVR (9%), 2 AVR-CABG (18%), 2 MVR (50%), 1 MVR-CABG (33%) and 2 AVR-MVR-CABG (67%). Statistical analysis of 22 perioperative variables suggested that a preoperative intraaortic balloon, a history of congestive heart failure, mitral valve replacement, urgent operation, need for preoperative inotropic support and the number of anastomoses performed were significant or marginally significant (P less than 0.15) univariate predictors of operative mortality. Multivariate analysis revealed that the need for a preoperative intraaortic balloon (F = 13.1), history of congestive heart failure (F = 6.8), and MVR (F = 6.7) were significant (P less than 0.001) independent predictors of mortality. Postoperative complications included arrhythmias in 36 patients (35%), respiratory insufficiency in 11 (11%), reversible neurological deficit in 15 (14%), and a permanent neurological deficit in 6 patients (6%). Actuarial survival was 90% and 82% at 1 and 2 years, respectively. Seven of 86 (8%) long term survivors sustained a stroke in the follow-up interval. The mean follow-up of survivors was 23 +/- 19 months with a mean improvement in NYHA class of 1.4 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Background Management of asymptomatic mild aortic stenosis at the time of coronary artery bypass grafting (CABG) remains controversial. We have retrospectively analyzed a cohort of patients requiring aortic valve replacement (AVR) subsequent to CABG and compared their operative morbidity and mortality with that of a group receiving CABG and AVR simultaneously at the first operation. Methods Analysis is drawn from 28 patients who required AVR 8 ± 4 years subsequent to CABG (group A) and 175 patients receiving AVR along with CABG at the primary operation (group B). Groups were similar with respect to age, sex, risk factors for cardiac disease, extent of coronary artery disease, left ventricular function, New York Heart Association class, aortic valve area, number of grafts, and size of prosthesis inserted. Results Patients having AVR subsequent to CABG had a significantly prolonged aortic cross-clamp time and global myocardial ischemic time and incurred a twofold increase in operative mortality. The actuarial survival at 10 years was not significantly different between cohorts. In the 28 patients in group A, the aortic valve area during the period between operations decreased 0.05 mm 2 /y. Conclusions The operative mortality and morbidity of a second operation for AVR is high, but there is no significant difference in survival at 10 years. In at least a portion of patients having mild aortic stenosis at the time of CABG there will be progression of the stenosis necessitating reoperation at a later date.

The purpose of this study was to determine if the addition of potassium to reinfusion cold blood cardioplegia (CBC) offers an advantage over cold blood alone. Forty patients matched for age, left ventricular function, extent of coronary disease and number of vessels bypassed were prospectively randomized. Each patient received an initial dose of CBC (10 cc/kg) with potassium. Group I patients (n = 23) received subsequent infusions of CBC (5 cc/kg) containing potassium while Group II patients (n = 17) received cold blood only. The cross-clamp time, mean infusate volume and temperature were not significantly different in the two groups. Following reperfusion, the cardiac index and the CPK isoenzyme release at 0.5, 1, 8, and 12 h after cross-clamp release were not significantly different between the groups. The postoperative appearance of new Q-waves, inotropic agent requirement, and reversal of the lactate dehydrogenase (LDH) isoenzyme ratio were also not significantly different in the two groups. The study demonstrated that following initial arrest with potassium, cold blood is equally as effective as potassium blood cardioplegia in protecting the ischemic myocardium.

Prevention of ventricular fibrillation after aortic unclamping using lidocaine hydrochloride as an additive to cold potassium blood cardioplegia was studied prospectively in 46 patients undergoing elective myocardial revascularization. Patients were similar with respect to age, ventricular function, severity of coronary artery disease, cross-clamp time, completeness of revascularization, frequency of internal thoracic artery grafting, systemic temperature at the time of cross-clamp removal, and mean infusate volume and temperature. Patients receiving lidocaine blood cardioplegia (group 1, 23 patients) had a significant reduction in the incidence of ventricular fibrillation (22% versus 74%; p less than 0.0005) and in the mean number of cardioversion attempts required to defibrillate the heart (0.5 +/- 1.3 versus 1.9 +/- 0.97; p less than 0.0005) after cross-clamp removal compared with controls (group 2, 23 patients). There were no differences between the two groups postoperatively with regard to cardiac enzyme release, hemodynamic measurements, or clinical outcome. Patients receiving lidocaine blood cardioplegia tended to have a lower incidence of new postoperative atrial fibrillation (9% versus 26%). Ventricular function was preserved equally in both groups. We conclude that lidocaine is a safe additive to potassium blood cardioplegia and significantly reduces the incidence of ventricular fibrillation after aortic unclamping.

Noninvasive innovations have advanced the timing and precsion of diagnosis of acute dissection or enlarging aortic aneurysm. However, the need to perform coronary arteriography prior to surgical repair in these patients remains a question for many clinicians. This retrospective 10-year (1978 to 1988) review examined data of 54 patients undergoing urgent surgical repair of thoracic aortic tear, aneurysm, or dissection in our institution. Results of coronary arteriography and clinical variables (history of coronary artery disease, electrocardiographic abnormalities, surgical procedures, and in-hospital mortality) were tabulated. Twenty-seven patients had type A aortic dissection and 27 patients had type B. Twenty-four patients had aortic dissection or tear (type A or B) due to motor vehicle trauma. In patients with type A, a history and/or electrocardiogram suggestive of coronary artery disease was present in 16, in whom cardiac catheterization was performed in five. None required coronary bypass surgery or died. In the 11 patients with no clinical history of coronary artery disease or electrocardiographic abnormalities, six had cardiac catheterization, none had coronary artery disease, two had coronary reimplantation, and six died. Only 1 of the 27 patients with type A dissection had a perioperative myocardial infarction (a patient with a clinical history of coronary artery disease who did not undergo cardiac catheterization). In patients undergoing type B aortic repair, 10 had a clinical history or electrocardiogram consistent with coronary artery disease but only one underwent cardiac catheterization and subsequent coronary artery bypass graft surgery for coronary artery disease. Seventeen patients had no history of coronary artery disease, of whom only two had cardiac catheterization (no coronary artery disease, no deaths), with three deaths in the remaining 15—one with coronary artery disease found at autopsy. Death after aortic surgical repair in our series was most often due to postoperative bleeding complications without evidence of myocardial infarction. In patients with no prior history of coronary artery disease of electrocardiographic abnormalities, past and current surgical experience do not support routine use of coronary arteriography.

The prevalence and characteristics of silent myocardial ischemia as detected by 24-hour ambulatory electrocardiography ST-segment depression were prospectively assessed in 94 patients examined early (1 to 3 months) and 184 patients examined late (12 months) after coronary artery bypass grafting (CABG), and followed for a mean of 48 +/- 11 (range 4 to 62) months. The relation of ambulatory electrocardiographic silent ischemia to evidence of completeness of revascularization as defined by cardiac angiography performed 1 and 12 months after CABG, and to prognosis by follow-up of adverse clinical events was analyzed. Silent ischemia was detected early in 20% (19 of 94) and late in 27% (50 of 184) of patients, and showed a mean frequency of episodes ranging from 6 to 10 episodes/24 hours with a mean duration ranging from 15 to 23 minutes. The circadian distribution of episodes disclosed a significant peak of ischemic activity during the period of 6 A.M. to noon and a secondary peak between 6 P.M. and midnight (p less than 0.01 and p less than 0.001, respectively). Silent ischemia was not found by univariate analysis to be associated with graft or anastomotic site occlusions, low graft flow rates, grafted arteries with significant distal residual stenoses or ungrafted stenotic native coronary arteries. Kaplan-Meier analysis of time to cardiac event showed that silent ischemia was not predictive of an adverse clinical event in the early years after CABG. Cox regression analysis of 30 covariates only disclosed age (relative risk 1.06 [95% confidence interval, 1.01 to 2.94]) as having an effect on time to adverse clinical event.(ABSTRACT TRUNCATED AT 250 WORDS)

Blunt trauma leading to aortic valvular incompetence is rarely encountered, with 27 cases reported to date. All cusps and commissures are involved to a similar degree. Treatment includes either reattachment of cusps to the annulus (80% recurrence of incompetence) or valvular replacement (no recurrence). Valve replacement is the treatment of choice for these patients.

THE 1973 report by Garrett, Dennis, and DeBakey 1 on the long-term patency of an aortocoronary saphenous vein bypass graft established at an operation 9 years previously (November 1964) identifies a high plateau that had been reached in the search for a means to improve blood flow to the myocardium in the presence of flow-limiting coronary atherosclerosis. Few medical interventions have gained such investigative and clinical dominance as those procedures increasing blood flow to the heart. Now, 20 years subsequent to the demonstrated capability, close to a million procedures are performed annually in this country alone. This is especially remarkable considering that these procedures are not curative of the disease but treat only the consequences, termed by Lewis Thomas 2 as "half way technology." The malady, coronary artery occlusive disease, remains the leading cause of death in Western cultures in spite of rigorous attempts to control the alterable risk factors

Distribution of myocardial blood flow was studied during extracorporeal circulation in normal dog hearts. Clinical modalities frequently used to facilitate technical maneuvers were evaluated for their effects on distribution of blood flow and compared to ultrastructural changes. Results do not indicate that changes in distribution alone are responsible for subendocardial ischemia. Anoxia and resultant edema are more important. Protection is provided by topical hypothermia.

A servocontrol system was developed to regulate a single roller pump left atrial-aortic (La-A) assist device. Responsiveness of the servomechanism to blood volume changes, myocardial damage, and mitral regurgitation was evaluated in 5 sheep and 6 dogs. Myocardial damage was induced by occlusion of coronary arteries, and the hemodynamic effects of La-A assistance were evaluated. While La-A assistance reduced left atrial pressures to low levels, the left ventricular end-diastolic pressure remained elevated in the severely damaged heart. La-A assistance was used in 3 patients. Two were weaned from cardiopulmonary bypass after failure of intraaortic balloon counterpulsation, and 1 is a long-term survivor. The third was supported for 48 hours after attempted repair of complex congenital heart disease. The servocontrol device added to the safety of prolonged La-A assistance. This mode of assistance should be considered when intraaortic balloon counterpulsation has failed.

Intraaortic balloon (IAB) assistance in 64 patients over 2 1/2 years has resulted in a survival rate of 11% (1 patient) when used alone but 47% when utilized in patients treated surgically (long-term survival, 38% [21 patients]). Patients undergoing coronary artery bypass grafting or aortic valve replacement have a long-term survival of 50% (8 and 9 patients, respectively). The required duration of IAB support has a bearing on the clinical result. Complications have been minimal. Though it was originally developed to assist in the nonoperative management of complications of ischemic heart disease, IAB assistance offers significant promise as an adjuvant to operative therapy for both ischemic and valvular heart disease.

Between August 1980 and January 1986, 23 patients aged 80 years or older underwent coronary artery bypass grafting (CABG) operations. These patients had a higher incidence of severe left main coronary artery narrowing (p less than 0.0001), 3-vessel coronary artery disease (p less than 0.05) and moderate to severe left ventricular dysfunction (p less than 0.05) than patients in the Coronary Artery Surgery Study registry older than 65 years. Of 14 patients undergoing elective simple CABG procedures, none died; of 19 elective cases overall, 2 patients died (11%). Three of 4 patients undergoing emergency procedures (75%) and 4 of 6 patients (67%) requiring intraaortic balloon counterpulsation died. Significant complications occurred in 9 of 18 survivors (50%). All operative survivors improved at least 1 New York Heart Association class, with a mean classification improvement of 3.7 to 1.6 (p less than 0.0001); 13 of 16 long-term survivors were in class I or II. Actuarial survival at 1 and 2 years is 94% and 82%, respectively. CABG can be performed electively in octogenarian patients with increased but acceptable mortality and morbidity risks. Functional improvement and long-term survival are excellent.

It has been suggested that coronary artery bypass grafting (CABG) performed in the setting of emergent failure of percutaneous transluminal coronary angioplasty causes minimal increased risk compared with routine CABG. We reviewed the records of 103 patients undergoing emergency CABG for failed percutaneous transluminal coronary angioplasty (group 1) and compared them with an identical number of consecutive CABG patients from 1987 (group 2). Group 1 had a lower risk profile evidenced by lower mean age (p less than 0.01), fewer diseased vessels (p less than 0.0001), better ventricular function (p less than 0.001), fewer left main lesions (p less than 0.0001), and fewer patients with acute ischemia requiring intravenous administration of nitroglycerin (p less than 0.01). Despite these differences, the group 1 patients had a higher mortality rate (11% versus 1%; p less than 0.01) and a higher rate of perioperative infarctions (new Q wave) (22% versus 6%; p less than 0.01). An analysis of risk factors was performed in the group 1 patients using 36 preoperative and operative variables. Multivariate analysis revealed that left ventricular score (p less than 0.0001), preoperative (after percutaneous transluminal coronary angioplasty) need for inotropic support (p less than 0.005), and age (p less than 0.025) were independent predictors of operative mortality. In conclusion, emergency CABG after failed percutaneous transluminal coronary angioplasty carries a significantly greater risk of operative death and perioperative infarction than elective CABG.

Of 2,782 patients undergoing isolated coronary artery bypass grafting (CABG) from 1970 through 1979, 196 exhibited severe global impairment of left ventricular (LV) wall motion preoperatively (LV score, greater than or equal to 15; ejection fraction, less than 0.40 in all patients and less than 0.30 in 67%). The initial 89 patients (Group 1) underwent CABG without potassium chloride cardioplegia. The subsequent 107 patients (Group 2) were given potassium chloride cardioplegia intraoperatively. Group B patients received more grafts per patient (3.1 versus 2.5; p less than 0.001) and were completely revascularized more often (72.9% versus 58.4%; p less than 0.05). Operative mortality was lower in Group B (3.7% versus 12.4%; p less than 0.025), and 5-year cumulative survival was better in Group B (88.8% versus 63.9%; p less than 0.0001). Preoperative congestive heart failure resulted in higher operative mortality (14.3% versus 4.5%; p less than 0.05) and lower 5-year survival (65.0% versus 81.8%; p less than 0.02). Complete revascularization led to higher 5-year survival (82.2% versus 66.0%; p less than 0.02) but did not alter operative mortality significantly (6.9% versus 9.1%). Potassium chloride cardioplegia may influence operative survival favorably by reducing perioperative myocardial infarction in patients with severe LV dysfunction. Long-term survival relates to completeness of revascularization and severity of congestive heart failure as variables independent of methods of myocardial protection.

The use of corticosteroids in the management of acute nonoperative myocardial infarction (MI) is controversial, but experimental evidence indicates reduction of infarct size with steroid treatment. Corticosteroids are also felt to be beneficial in low-flow states because of membrane stabilization. Methxlprednisolone (MP) effectiveness in limitation/prevention of perioperative Ml was assessed by serial ECG and serum LDH, SGOT, CPK, and CPK-MB measurements during the postoperative period in 150 patients. Of these, 75 randomly selected, received 2 Gm. of MP ½ hour prior to institution of cardiopulmonary bypass (CPB). There was no difference between the groups in operative technique, patient age, previous Ml, angina severity, graft number, CPB duration, myocardial ischemia duration, or graft patency. Four patients required ionotropic and intra-aortic balloon counterpulsation before removal from CPB could be accomplished. Three of these patients were in the treated group, and the only operative death occurred in the MP group. Analysis of enzymes did not further discriminate the incidence of MI or provide evidence of reduction of ischemic injury in the MP group. Nine patients in each group demonstrated ECG evidence of myocardial injury. New Q wave ST-T change, 48 nr. Total patients MP 6 3 9 No MP 5 4 9 Methylprednisolone did not reduce the incidence of perioperative myocardial injury during CABG.

From 1972 to 1987, seven patients, from two to 28 months of age, underwent left subclavian artery-left coronary artery anastomosis for anomalous origin of the left coronary artery from the pulmonary trunk. All of these infants, median age 4 months, had severe congestive heart failure caused by anterolateral myocardial infarctions. There were two hospital deaths (29% mortality rate) with no late deaths after an average 10-year follow-up. All survivors have good exercise tolerance New York Heart Association class I), reduction in heart size, and significant improvement or normalization of ventricular function by echocardiography. Patency of the subclavian-left coronary artery anastomosis has been documented in two of four patients who have undergone catheterization. In contrast to other revascularizing procedures for treatment of an anomalous origin of the left coronary artery, anastomosis of the left subclavian to the left coronary artery may be performed without cardiopulmonary bypass or aortic occlusion. Moreover, this procedure appears to have an acceptable mortality rate with excellent long-term functional results in critically ill infants.

Of 531 patients who underwent coronary artery bypass grafting during 1970 to 1973, 181 were restudied by ventriculography and by graft and coronary angiography at least 5 years following operation. Five patterns of postoperative ventricular function were identified: improved ventricular function resulting in normal left ventricular (LV) function; normal ventricular function that was unchanged; abnormal ventricular function that improved but did not reach normal; abnormal ventricular function that remained unchanged; and deterioration of LV function. Patients who regained (40) and those who retained normal ventricular function (49) comprise 49% of the series and patients with deterioration of ventricular function, only 20%. Graft patency and angina relief were significantly better in those with normal LV function than in those with LV deterioration. Progression of disease in grafted coronary arteries was similar in all groups, but was significantly higher in ungrafted coronary arteries (61.3%) in the patients showing deterioration than in either the improved patients or those with an unchanged normal LV (33.3% each) (p less than 0.05). The high incidence of progression of disease in ungrafted coronary arteries in the group with deterioration suggests that low graft patency and deterioration of ventricular function in this group might both be related to intrinsic acceleration of coronary atherosclerosis unrelated to operative intervention.

The long-term effects of the superior vena cava–pulmonary artery anastomosis were evaluated in 15 patients a mean of 8.5 years postoperatively. There were eight patients with tricuspid atresia and seven with other complex anomalies. Ten patients underwent 133xenon ventilation scans and 99mtechnetium perfusion scans in the upright and supine positions. Perfusion scans showed decreased perfusion of the right upper lobe which improved in the supine position. Shunt flow, measured by thermodilution in nine patients, was a mean of 1.7 L. per minute per square meter, with a mean superior vena caval pressure of 8 mm. Hg and a resistance of 3.0 units. Right and left pulmonary venous saturations were 94 and 96 percent, respectively, showing little intrapulmonary shunting. Venous collaterals were the major cause for shunt failure. Six patients underwent a left Blalock-Taussig shunt and division of venous collaterals a mean of 6 years after the Glenn shunt and are all doing well. The superior vena cava–pulmonary artery anastomosis did not result in progressive pulmonary deterioration in the patients studied. The staged treatment of tricuspid atresia by the Glenn shunt followed by a systemic–pulmonary artery shunt and ligation of venous collaterals gives prolonged effective palliation.

As cardiac transplantation becomes more commonplace in the treatment of end-stage heart failure and as suitable donors become less available, an increasing number of patients will require mechanical circulatory assistance to bridge to transplantation. Since 1982, refractory hemodynamic instability requiring placement of pulsatile ventricular assist devices (VADs) has developed in 11 candidates for transplantation aged 24 to 54 years (mean, 39.6 years). A pneumatic Pierce-Donachy pump was used in 9 patients and an electrical Novacor pump in 2. The cause of the cardiomyopathy was ischemic in 6, postpartum in 2, idiopathic in 2, and doxorubicin hydrochloride toxicity in 1. Seven patients required left ventricular support (LVAD); 4 required biventricular mechanical support (BVAD). Duration of support ranged from 8 hours to 91 days with flows ranging from 4.1 to 8.5 L/min (mean, 5.5 L/min). Although hemodynamic stability was achieved in all 11 patients, contraindications to transplantation developed in 5 patients during VAD support (renal failure in 4, sepsis in 3, disseminated intravascular coagulopathy in 1). The remaining 6 patients (4 with an LVAD, 2 with a BVAD) remained good candidates for transplantation despite major complications in 5 (mediastinal bleeding in 3, driveline infection in 3, development of preformed antibodies in 2, small embolic stroke caused by device malfunction in 1). The 3 patients who were supported the longest (24, 75, and 91 days) were ambulatory while awaiting a donor heart. All 6 patients underwent successful transplanation after 8 hours to 91 days (mean, 24 days) of support. Other than one sternal wound infection, there were no major complications after transplantation. The 6 survivors have been followed 4 to 30 months (mean, 14 months) with 1 late death due to medical noncompliance; the remaining 5 patients are in New York Heart Association Functional Class I. These results indicate that pulsatile VADs can provide prolonged hemodynamic support prior to transplantation with good preservation of end-organ function. Using strict criteria for determining suitability for transplantation, successful short-term outcome in this series was uniform.

Blood flow has been measured in 28 aortocoronary saphenous vein bypass grafts performed for chronic angina pectoris using the electromagnetic flowmeter. Nitroglycerin, 0.4 mg. intravenously or 0.1 mg. into the graft, and papaverine 30 mg. intravenously or 15 mg. into the graft, were studied. Intravenous nitroglycerin increased coronary flow a maximum of 4 per cent for 20 seconds followed by 23 per cent decline as mean arterial pressure fell 23 per cent. Intra-arterial nitroglycerin increased coronary flow 74 per cent in 15 seconds with return to control by 90 seconds. Intravenous papaverine elevated coronary flow 76 per cent at 30 seconds with stabilization of flow 15 to 20 per cent above control. Intra-arterial papaverine achieves a maximum flow of 215 per cent at 45 seconds with return to control at five minutes. Although nitroglycerin produces a small but significant rise in coronary flow it is doubtful whether this increase occurs with oral administration in the presence of coronary disease. Thus, the therapeutic effect of nitroglycerin lies in its systemic effects rather than in its coronary effect.

A Working Group appointed by the Director of the National Heart, Lung, and Blood Institute (NHBLI) has reviewed the current status of mechanical circulatory support systems (MCSS), and has examined the potential need for such devices, their cost, and certain societal and ethical issues related to their use. The media have reported the limited clinical investigative use of pneumatically energized total artificial hearts (which actually replace the patient's heart) and left ventricular assist devices (which support or replace the function of the left ventricle by pumping blood from the left heart to the aorta with the patient's heart in place). However, electrically energized systems, which will allow full implantation, permit relatively normal everyday activity, and involve battery exchange or recharge two or three times a day, are currently approaching long-term validation in animals prior to clinical testing. Such long-term left ventricular assist devices have been the primary goal of the NHLBI targeted artificial heart program. Although the ventricular assist device is regarded as an important step in the sequence of MCSS development, the Working Group believes that a fully implantable, long-term, total artificial heart will be a clinical necessity and recommends that the mission of the targeted program include the development of such systems. Past estimates of the potential usage of artificial hearts have been reviewed in the context of advances in medical care and in the prevention of cardiovascular disease. In addition, a retrospective analysis of needs was carried out within a defined population. The resulting projection of 17,000-35,000 cases annually, in patients below age 70, falls within the general range of earlier estimates, but is highly sensitive to many variables. In the absence of an actual base of data and experience with MCSS, projection of costs and prognoses was carried out using explicit sets of assumptions. The total cost of a left ventricular assist device, its implantation and maintenance for a projected average of 4 1/2 years of survival might be approximately $150,000 (in 1983 dollars). The gross annual cost to society could fall in the range of $2.5-$5 billion. Ethical issues associated with use of the artificial heart are not unique. For individual patients these relate primarily to risk-benefit, informed consent, patient selection, and privacy. However, for society as a whole, the larger concern relates to the distribution of national resources.(ABSTRACT TRUNCATED AT 400 WORDS)

Cold blood with potassium, 34 mEq/L, was compared with cold blood and with a cardioplegic solution. Three groups of 6 dogs had 2 hours of aortic cross-clamp while on total bypass at 28 degrees C with the left ventricle vented. An initial 5-minute coronary perfusion was followed by 2 minutes of perfusion every 15 minutes for the cardioplegic solution (8 degrees C) and every 30 minutes for 3 minutes with cold blood or cold blood with potassium (8 degrees C). Hearts receiving cold blood or cold blood with potassium had topical cardiac hypothermia with crushed ice. Peak systolic pressure, rate of rise of left ventricular pressure, maximum velocity of the contractile element, pressure volume curves, coronary flow, coronary flow distribution, and myocardial uptake of oxygen, lactate, and pyruvate were measured prior to ischemia and 30 minutes after restoration of coronary flow. Myocardial creatine phosphate (CP), adenosine triphosphate (ATP), and adenosine diphosphate (ADP) were determined at the end of ischemia and after recovery. Changes in coronary flow, coronary flow distribution, and myocardial uptake of oxygen and pyruvate were not significant. Peak systolic pressure and lactate uptake declined significantly for hearts perfused with cold blood but not those with cold blood with potassium. ATP and ADP were lowest in hearts perfused with cardioplegic solution, and CP and ATP did not return to control in any group. Heart water increased with the use of cold blood and cardioplegic solution. Myocardial protection with cold blood with potassium and topical hypothermia has some advantages over cold blood and cardioplegic solution.

The effect of cardiopulmonary bypass (CPB) on myocardial extravascular water (MEW) was evaluated with crystalloid and colloid hemodilution. Heart water was measured gravimetrically and by the double-indicator and thermal methods. CPB without hemodilution resulted in a 5.7 per cent increase in the wet:dry weight ratio of the left ventricle obtained by desiccation to stable weight. CPB with colloid hemodilution to a hematocrit of 10.7 ± 0.4 per cent resulted in a 5.4 per cent increase in the wet:dry weight ratio. Crystalloid hemodilution to a hematocrit of 9.5 ± 0.8 per cent resulted in a marked increase in myocardial water with a wet:dry weight ratio 30.3 per cent greater than the controls. Hypothermic (22° C.) crystalloid hemodilution resulted in a 37.4 per cent increase in the wet:dry weight ratio. MEW was also measured by the double-indicator method with Evans blue dye and tritiated water. This method measured 85 per cent of the gravimetrically measured water. Although it indicated the increase in heart water in the crystalloid groups, it proved less reliable in the measurement of MEW in this dynamic situation. The thermal heart water was also measured with an impedance and thermistor-bearing catheter similar to that used to measure thermal lung water. This proved ineffective in measuring heart water. Colloid hemodilution was thus found to prevent the development of myocardial edema which occurred with crystalloid hemodilution (p

From January 1972 through December 1974, at Saint Louis University Medical Center (SLU), 345 patients similar to those of the VA Cooperative Coronary Artery Study received CABG. Operative mortality was SLU 2.3%, VA 5.6% (p < 0.05). Perioperative myocardial infarction rate was SLU 8.4%, VA 18% (p < 0.005). One year graft patency was SLU 87%, VA 71%; all grafts patent SLU 76%, VA 54%; at least one graft patent SLU 96%, VA 89%. SLU angina pectoris relief at five years was 90%. SLU patients free of myocardial infarction five years postoperatively was 83%. Comparative cumulative four year survivals were: [Table: see text] Cumulative four-year survival in 272 SLU patients (79%) completely revascularized was 94%, compared to SLU entire group of 95%, VA medical 86% (p < 0.002) and VA surgical 85% (p < 0.002). Comparing 1972-74 SLU results to VA medical and surgical groups, CABG prolonged life in patients with double and triple vessel disease and in those completely revascularized.

The technique of repair of pulmonary atresia with intact ventricular septum is described. The porcine valved conduit (Hancock) was placed so that the valve was in the "anatomic" position, avoiding compression by the sternum. There was a mild gradient (15 mm. Hg) at a cardiac index of 4 L. per minute per square meter across the porcine valve itself, measured at the postoperative catheterization. The valve orifice diameter was only 15 mm., which is considerably less than the 22 mm. valve annulus. The possible merits of this procedure over the conventionally placed valved conduit and over an outflow tract patch are discussed.

Unstable angina pectoris is a broad, nonspecific diagnosis encompassing a wide variety of clinical syndromes. The intravenous administration of nitroglycerin preoperatively is indicative of a more acute clinical situation, and allows for selection and analysis of a more homogeneous patient population. We reviewed the results of coronary artery bypass grafting for unstable angina defined as angina necessitating intravenous administration of nitroglycerin preoperatively. There were 129 patients (83 men and 46 women) with a mean age of 63.2 years (range, 36 to 86 years). Complications included operative death in 6.2%, postoperative low cardiac output in 11%, and perioperative myocardial infarction in 9%. Twenty perioperative variables were analyzed to identify risk factors for these end points. For operative death, age (p less than 0.05), cross-clamp time (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant in the univariate analysis, but only age (p less than 0.05, F = 4.6) was an independent predictor using multivariate analysis (stepwise linear regression). For low cardiac output, univariate analysis demonstrated that cross-clamp time (p less than 0.01), preoperative use of an intraaortic balloon for angina (p less than 0.05), left ventricular score (p less than 0.05), number of diseased coronary vessels (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant variables. However, only use of an intraaortic balloon for angina (p less than 0.0001, F = 14.3) and left ventricular score (p less than 0.005, F = 11.1) were significant independent predictors in the multivariate model. For perioperative myocardial infarction, only diabetes requiring insulin (p less than 0.005) was a significant predictor.

Patients having coronary bypass for stable angina pectoris were grouped on the basis of the two hour plasma sugar of the glucose tolerance test: Group I, 120 mgs% (159 grafts); Group II, 120-150 (93 grafts); Group III, 150-200 (131 grafts) and Group IV, 200 (57 grafts) or patients receiving therapy for diabetes mellitus (10 patients, 21 grafts). Five of 10 diabetic patients had genetic evidence of diabetes and an average duration of therapy of 6.5 years. Blood flow was measured in 461 grafts with an electromagnetic flow probe after discontinuation of cardiopulmonary bypass in a stable state, after a 30 second graft occlusion and after injection of 15 mg of papaverine into the graft. Mean arterial pressure, graft flow and coronary resistance for each succeeding group did not vary significantly when compared with Group I. Analysis of phasic flow in 10 grafts to the left anterior descending indicates that the same proportion of flow occurs during systole and diastole in the basal state and after pappaverine. Coronary flow and resistance in patients with abnormal glucose metabolism and maturity onset diabetes do not provide evidence for the existence of myocardial microangiopathy.

This study retrospectively examines 447 patients with minimal or absent angina found to have significant coronary artery disease (CAD) by coronary arteriography. Patients with left main coronary stenosis, valvular heart disease, or ventricular aneurysm were excluded. Treatment choice was nonrandom—more medically treated patients had single-vessel disease, normal left ventricular contractility, or absence of angina. Isolated coronary artery bypass grafting (CABG) was performed in 284 patients; of 163 patients initially managed nonoperatively, 22 subsequently crossed over to surgical treatment because of increasing angina. Average followup is 38.6 months (range 18 to 64). There was an important, but not statistically significant, difference in the 3 year cumulative survival rate—surgical 98.3% (70% CL 97.6% to 100%) versus medical 94.1% (70% CL, 91.7% to 96.5%) p = 0.077. There was only one noncardiac death and there were three nonfatal myocardial infarctions in patients with single-vessel disease, regardless of therapy. In patients with multivessel disease, the 3 year cumulative survival rate was significantly better in the surgical (98.6%) than the medical group (91.5%) p = 0.031. Event-free 3 year survival rate (death, myocardial infarction, crossover to surgical therapy, or reoperation) was significantly better in surgically treated patients overall (90.4% versus 73.5%, p = 0.000041), as well as in surgically treated patients with double- or triple-vessel disease taken as separate subsets. Angina relief was also significantly better with surgical treatment (74.6% versus 44.3%, p

Impedance reduction with a continuous infusion of hydralazine was evaluated in 20 patients following cardiopulmonary bypass. Patients were selected for therapy when the cardiac index (CI) was less than 2.2 L/m2/min, when the systemic vascular resistance index (SVRI) was greater than 2,500 dyne sec cm-5, or when both conditions were present. No other vasoactive or cardiotonic drugs were used intraoperatively or postoperatively. Responses were measured at 15, 30, 60, 120, 180, and 240 minutes and compared with control measurements. Significant responses appeared by 15 minutes in the mean arterial pressure, CI, and SVRI, which were maximal by 2 hours. At 4 hours, the SVRI was 1,520 +/- 276 dyne sec cm-5 (control, 3,235 +/- 222) and pulmonary vascular resistance index, 365 +/- 102 dyne sec cm-5 (control, 592 +/- 71). The CI was 3.20 +/- 0.29 L/m2/min (control, 1.96 +/- 0.16) and mean arterial pressure, 75 +/- 2.3 mm Hg (control, 92 +/- 2.4). Left atrial, pulmonary artery diastolic, and right atrial pressures increased from control but not significantly: 11.4 +/- 0.8 to 13.3 +/- 1.2 mm Hg, 13.6 +/- 1.6 to 17.2 +/- 1.5 mm Hg, and 6 +/- 1.6 to 9.4 +/- 1.7 mm Hg, respectively. In 16 patients, hydralazine was continued for 24 hours and in 11, the transition to oral therapy was made. Hydralazine by infusion effectively reduces after load, avoids the fluctuations of bolus therapy, and allows the transition to oral therapy if needed.

Advances in prosthetic devices led to our analysis of revascularization in patients presenting with gangrene of the lower extremity. Between 1966 and 1976, 99 grafts were performed on 96 of the 249 patients treated by lower extremity revascularization who presented with the above criteria. Their mean age was 66 years; 46 (48%) were diabetic, 53 (55%) were over the age of 65, and 38 (40%) had angiographically proven disease with one vessel runoff. Initial therapy consisted of intravenous antibiotics and local debridement to control sepsis, followed by detailed arteriography. Femoral-popliteal bypass was per formed in 87 patients, and a more distal vessel was utilized in 9. There were 5 in- hospital deaths. Of these, 4 patients had come to major amputation. Four died as a result of myocardial infarctions, and 1 as a result of a cerebrovascular accident. Immediate graft patency was achieved in 93 of 99 patients (93%). Minor amputations were required in 44 patients. Early graft failure resulted in major amputations in 7 patients. A late major amputation (mean 13 months) was required in an additional 28 patients, 15 because of graft failure and 13 because of nonhealing minor amputations. Extremity salvage at 2 years was achieved in 72 of the 99 patients (72%).

The late sequelae of myocardial injury occurring at the time of direct myocardial revascularization are unknown. Fifty of 500 consecutive patients undergoing aortocoronary bypass grafting developed both electrocardiographic and enzymatic evidence of myocardial injury. They were matched with 50 patients of similar age, sex, history of previous infarction, severity of angina, degree of coronary arteriosclerosis, and level of ventricular function as determined by preoperative angiographic studies. The conduct of the operation was identical in each group except for prolongation of total cross-clamp time in those patients with myocardial injury. The total number of vessels grafted, the conduit used, and the operative mean graft flow were similar. Results of treadmill stress testing at 24 to 36 months were not significantly different between groups. Angina status, long-term survival, graft patency, and ventricular function were not adversely affected by intraoperative myocardial injury. However, postoperative ventricular function and stress test performance were related to graft patency.

Fifty cyanotic patients (aged 2 days to 22 years) underwent Glenn shunts for tricuspid atresia and other cyanotic heart defects. Thirteen of 15 operative deaths occurred in infants less than 4 months old, and only 1 death has occurred in the last 9 years. Results were poor in patients with Ebstein's anomaly, truncus arteriosus, transposition of the great vessels, and complex defects other than tricuspid atresia and univentricular heart. Of the 35 patients followed from 0.9 to 14.8 years, 12 were followed for more than 10 years. None of the 11 late deaths could be attributed to complications of the shunt. Minimal evidence of intrapulmonary shunting was found by angiography, pulmonary venous oximetry, or radioisotopic studies. Late deterioration due to venous collaterals and decreased flow to the opposite lung necessitated Blalock-Taussig shunts in 6 and Fontan procedures in 10. All survived the Fontan procedures with minimal morbidity. These data support the concept that Glenn shunts do not necessarily result in pulmonary abnormalities and may be indicated as a staged procedure in a few selected patients prior to a Fontan procedure.

We compared 147 consecutive patients who had left coronary ostial stenosis with 254 consecutive patients who had left main coronary artery stenosis treated with coronary artery bypass grafting. Mean age for the left main group was 61.6 years versus 59.7 years for the left ostial group (p = not significant [NS]). In the left ostial group, 43.5% were female and in the left main group, 12% (p less than 0.005). Prior myocardial infarction had occurred in 53% of patients with left main stenosis and 36% of patients with left ostial stenosis (p less than 0.005). There were 2.45 +/- 1.00 diseased vessels in the left main group and 1.96 +/- 1.09 in the left ostial group (p less than 0.0005). Seven (3%) of the patients with left main stenosis had no associated coronary disease (greater than 50%) versus 24 (16%) of the left ostial group (p less than 0.005). The degree of left main stenosis was 90% or more in 28.3% of patients versus 42.8% with equivalent ostial narrowing (p less than 0.01). Left ventricular function was better in the left ostial group than in the left main group (1.61 +/- 0.93 versus 2.02 +/- 1.11, respectively; p less than 0.0005). One-month mortality was 10 patients (3.9%) in the left main group and 8 (5.4%) in the left ostial group (p = NS). Perioperative infarction occurred in 8.6% of patients with left main stenosis and 4.7% of patients with left ostial stenosis (p = NS). Mean follow-up was 6.1 years for the left main group and 5.4 years for the left ostial group.(ABSTRACT TRUNCATED AT 250 WORDS)

During an 8 year interval, 184 patients with symptomatic single-vessel disease underwent coronary artery bypass grafting (CABG). There were no operative deaths and only one late cardiac death (5 year cumulative survival 97.9%). At 48 months mean follow-up, 91% are angina free or improved. The low incidence of perioperative and late myocardial infarction (MI) and the preservation of ventricular function seen on follow-up catheterization suggest that coronary bypass operations yield significant benefits in severely symptomatic patients with single-vessel disease. Evidence is presented which supports the idea that single-vessel coronary artery disease may be a unique manifestation of coronary atherosclerosis and not one stage in a continuum.