This study suggests that on-pump as compared with off-pump coronary artery bypass grafting is more deleterious to renal function in diabetic patients with non-dialysis dependent renal insufficiency. MDRD GFR is a more sensitive investigation than serum creatinine levels to assess renal insufficiency in patients undergoing coronary bypass.
Acute hemorrhage into an adenomatous goiter following cardiac surgery is a rare cause of acute upper airway obstruction. We report an unusual presentation of respiratory distress in a patient with goiter recovering from open heart surgery, which was successfully treated by left hemithyroidectomy. A mandatory evaluation of the upper trachea in patients with long-standing benign goiter is recommended prior to cardiac surgery.
Objective: We compared sternal wound infections between diabetic patients undergoing off-pump coronary artery bypass surgery using bilateral internal thoracic artery grafting or single internal thoracic artery grafting and nondiabetic patients receiving bilateral internal thoracic artery or single internal thoracic artery grafting using a modified pedicled harvest technique of internal thoracic artery.Methods: This retrospective study was conducted to analyze the data from 3072 patients who underwent primary coronary artery bypass surgery using an off-pump technique from August 2004 to October 2010. Of the 1211 diabetic patients, 181 received bilateral internal thoracic artery grafts (group 1) and 1030 received single internal thoracic artery grafts (group 2). Of the 1861 nondiabetic patients, 161 received bilateral internal thoracic artery grafts (group 3) and 1700 received single internal thoracic artery grafts (group 4). The incidence of postoperative sternal wound infections in diabetic patients who received bilateral internal thoracic artery grafting was compared with the incidence in other groups (group 2, 3, and 4). A modified technique of pedicled harvesting of the internal thoracic artery was done in patients receiving bilateral internal thoracic artery grafting, and a standard pedicled harvest was used in patients receiving single internal thoracic artery grafts.Results: No significant differences were present in the preoperative variables among the groups. The observed rate of superficial sternal wound infections in groups 1, 2, 3, and 4 was 1.1% (2 patients), 1.65% (17 patients), 1.86% (3 patients), and 1.65% (28 patients), respectively (P ¼ .9941). Deep sternal infections were observed in 1 (0.55%), 5 (0.48%), 1 (0.62%), and 14 patients (0.82%) in groups 1 through 4, respectively (P ¼ .8380). Multivariate analysis showed that bilateral internal thoracic artery harvesting (P ¼ .889), diabetes mellitus (P ¼ .96), and patient age were not predictors of sternal wound infection. Conclusions:The results of the present study show that there is no increase in the incidence of sternal wound infections in diabetic patients undergoing coronary artery bypass surgery with bilateral internal thoracic artery grafting by using a modified pedicle bilateral internal thoracic artery harvesting technique with sparing of the communicating bifurcation of internal thoracic artery to the chest wall and preservation of pericardiacophrenic artery branch.
IntroductionThe prevalence of patients presenting with severe left ventricular dysfunction is increasing together with an increasing profile of co-morbidities 1 . Severe left ventricular (LV) dysfunction has been reported as an independent predictor of operative mortality in patients undergoing coronary artery bypass grafting 1-4 . Offpump technique has theoretical and practical advantages over conventional coronary artery bypass grafting in this subset of high risk patients. Multiple studies showed that CABG results in considerable improvement in long-term survival, as well as, improvement in ejection fraction and symptomatic class 1,3 . Off-pump coronary artery bypass grafting (OPCAB) has become a valid treatment for coronary artery disease especially for those with cerebrovascular AbstractObjective : Off-pump coronary artery bypass grafting (OPCAB) is known to preserve left ventricular function better than conventional coronary artery bypass grafting (CCAB). This study was carried out to investigate the safety, feasibility and efficacy of off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction. Methods: Three hundred and eighty eight consecutive patients with preoperative left ventricular ejection fraction < 39% who underwent CABG between January 2001 through October 2007 were included in this retrospective study. Two hundred and eleven patients were operated by off-pump technique (group 1) and 178 patients were operated by on-pump technique (CCAB) (group 2). The postoperative outcomes were analyzed. Of these, 204 (52.57%) patients were diabetics, 355 (91.49%) patients had documented prior myocardial infarction, 316 (81.44%) patients were in canadian cardiovascular society(CCS) class III and 47 (12.11%) patients were in CCS class IV.Results: There was no significant difference in the number of grafts per patient between the two groups [group 1 3.02 ± 0.76 vs group 2 3.18 ± 0.72 (P=0.07) and the index of completeness of revascularization was comparable [1.08 ± 0.08) (OPCAB) vs 1.04 ± 0.06 (CCAB) (p=0.52)] The left internal thoracic artery was anastomosed to left anterior descending artery in 98% of patients. Operative mortality was 2.8% (6 deaths) following OPCAB and 3.93% (7 deaths) following CCAB (p=0746). Postoperative usage of IABP support was higher in CCAB group (12 patients vs 4 patients: P<0.03) and usage of moderate or higher doses of inotropic support was also higher in the conventional group (p<0.0006). More worsening of preexisting renal insufficiency was observed in CCAB group (p=0.01) and no significant difference in the incidence of atrial fibrillation was observed between the groups.Conclusions: Off-pump coronary artery bypass grafting is feasible and safe in patients with depressed left ventricular function and the postoperative morbidity was less in OPCAB group compared to on-pump group. (Ind J Thorac Cadiovasc Surg 2008; 24: 110-115)
Background: As the incidence of coronary artery disease (CAD) at young age is high in Asian countries, the number of coronary reoperations in this group of patients is increasing. The aim of this study was to define the incidence, risk factors and to discuss the methods of re-revascularization and early to mid-term outcomes in these patients.Methods: This study is a retrospective analysis of the data of patients who underwent primary coronary artery bypass surgery (CABG) before the age of 45 years and underwent reoperation for recurrence of angina due to progression of native coronary artery disease and, or, graft occlusion. The data was also analyzed with regards to the risk factors contributing to the recurrence of the disease and the short to mid-term outcomes. During a six year period from January 1998 to October 2004, a total of 68 patients had reoperation for recurrence of angina. The mean interval of presentation following primary CABG was 12.48 _+ 3.11 years (ranged from 8 months to 16 years). Reoperation was performed under cardiopulmonary bypass (CPB) in 63 patients and in the remaining five patients on beating heart without using CPB.Results: Reoperation accounted for 4.6% of 2478 patients who underwent CABG between January 1998 through October 2004 at our institute. Among these 114 patients, 68 patients underwent primary CABG before the age of 45 years. These 68 patients received a total of 214 grafts (3.14 grafts per patient) of which 169 grafts were re-anastamosed to previously grafted target arteries. Left internal mammary artery was used in 61 patients (89.7%) who required graft to left anterior descending coronary artery at reoperation. The early mortality was 4.4% (3 out of 68). Two patients (2.94%) had perioperative myocardial infarction and two more patients were re-explored for mediastinal bleeding. Freedom from recurrence of symptom of angina at 2 and 4 years was 98.01%, 94.5% respectively.Conclusions: Redo CABG is associated with higher morbidity and mortality when compared to first-time CABG. Perioperative myocardial infarction and left ventricular dysfunction contribute significantly to the increased risk of redo CABG. (Ind J Thorac Cardiovasc Surg, 2005; 21: 199-203)
Postinfarction rupture of the interventricular septum is usually fatal without prompt surgical intervention. Repair of postinfarction ventricular septal rupture by an endocardial patch technique with infarct exclusion is associated with less morbidity and mortality. The results of this repair in 22 consecutive patients were analyzed retrospectively. After myocardial infarction, 16 patients were operated on within 7 days, 3 at 8-21 days, and 3 at 3-6 weeks. 2D-echocardiography, color Doppler studies and coronary angiography were performed in all patients prior to surgery. The mean age of the patients was 57.46 +/- 5.31 years and 20 were male; 15 were in cardiogenic shock or congestive heart failure at the time of operation. There were 5 (22.7%) operative deaths. Postoperative complications included low cardiac output, renal failure and respiratory failure. Preoperative cardiogenic shock, severe right ventricular dysfunction, residual ventricular septal defect, and preoperative renal failure were predictors of operative mortality. There were 2 late deaths. A rapid diagnosis, aggressive medical management and prompt surgical intervention are required to optimize survival and recovery in patients who present with septal rupture complicating myocardial infarction.
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