The objective of this study is to develop a simple risk score to predict 30-day mortality of aortic valve replacement (AVR).

AIM:To correlate supraclavicular ultrasonography with angiographically patent and string sign left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafts.METHODS:Sixteen patients with a single LIMA anastomosis to the LAD were prospectively entered in a follow-up study. The supraclavicular ultrasonography of the LIMA origin was studied preoperatively and at 5.3+/-3.6 months and 1.7+/-0.4 year postoperatively. At the late postoperative ultrasonography electrocardiographically controlled hyperemic response was also studied for 6 min. Control angiography was performed at 1.5+/-0.8 year. Differences within groups were tested with a paired t-test and between groups with an unpaired t-test.RESULTS:Control angiography showed in 13 patients (group I) a patent LIMA graft and in 3 patients (group II) a string sign LIMA graft. Preoperative blood velocities were not significantly different between groups. Postoperatively, both groups revealed higher diastolic and lower systolic blood velocities compared to preoperative values. The blood velocities at rest did not change in group I and all velocities decreased in group II in time postoperatively. The blood velocities in maximal hyperemic response increased significantly within the groups and were not significantly different between the groups. No ischemia could be detected electrocardiographically during hyperemic response and no patient presented angina.CONCLUSIONS:Both groups showed a shift towards coronary type diastolic blood velocities at rest and at hyperaemic response. Significant hyperemic response was also present in string sign LIMA grafts and demonstrates response capacity to increased myocardial oxygen demand.

The internal mammary artery (IMA) is the conduit of choice in coronary revascularization because of its long-term patency. We analyzed the effect of left internal mammary artery (LIMA) harvesting on sternal perfusion. Diameters and velocity parameters of the nonmobilized right internal mammary artery (RIMA) were noninvasively analyzed with duplex ultrasound in 41 patients with LIMA myocardial revascularization pre- (2.6 +/- 5 days) and postoperatively (4.9 +/- 3.9 months). Data of 41 patients were analyzed; 38 patients underwent all examinations with adequate supraclavicular signals. The proximal RIMA diameter and all velocity parameters increased significantly at follow-up (3.1 +/- 0.6 vs. 3.2 +/- 0.5 mm, p = 0.03; diastolic peak velocity [DPV] 15 +/- 7 vs. 27 +/- 9 cm/sec, p < 0.0001; systolic peak velocity [SPV] 90 +/- 24 vs. 105 +/- 29 cm/sec, p < 0.02). This was more pronounced for the diastolic parameters and for all parameters in the proximal part of the RIMA than in the distal part (DPV 11.9 +/- 10.1 vs. 9.5 +/- 10.2 cm/sec, p = NS; SPV 14.9 +/- 33.9 vs. 7.4 +/- 26.0 cm/sec, p = NS). With longer time intervals of follow-up the increase in all diastolic velocity parameters became less pronounced. As demonstrated in the RIMA velocity parameters, patients with skeletonized LIMA grafts (n = 4) had significantly more flow, suggesting hyperemic flow, than patients with pedicled LIMA grafts (n = 34). Only in diastolic velocity integral (DVI) and systolic/diastolic velocity ratio (SDVRA) were there significant differences between diabetics (n = 9) and nondiabetics (n = 29) and only in DVI between female, (n = 8) and male (n = 30) patients. This study indicates that duplex ultrasound is a useful tool for noninvasive RIMA follow-up in LIMA myocardial revascularization.

Objective:In trying to answer the question about the controversial use of sequential grafts, we determined the long-term clinical outcome of patients in whom coronary artery bypass was done with different types of vein grafts.Methods: A total of 428 consecutive patients who underwent isolated coronary artery bypass with vein grafts between April 1, 1976, and April 1, 1977, were prospectively observed.In these patients three groups could be defined with single grafts only, sequential grafts only, and combined single and sequential grafts.Follow-up was 99.8% complete and averaged 15.4 years for the survivors.The Kaplan-Meier method and multivariate analysis done with the Cox regression model were used for survival, myocardial infarction, reintervention, and "any event."Results: Perioperative mortality and perioperative myocardial infarction rate were not statistically different among the three groups.During follow-up more myocardial infarctions (hazard ratio: 2.06; 95% confidence interval: 1.08 to 3.93;p = 0.0293) or any events (hazard ratio: 1.54; 95% confidence interval: 1.01 to 2.36; p = 0.0450) occurred in patients with sequential grafts only than in patients with single grafts only.Conclusion: Although more complete revascularization was obtained in patients with sequential vein grafts only, more events during a 15-year follow-up occurred in these patients than in patients with single vein grafts only.(

Graft replacement remains the procedure of choice for patients with thoracoabdominal aortic aneurysm. Since there is little information regarding the long-term survival following these major vascular operations which may carry a risk of various late complications, a retrospective analysis of 10 years follow-up was undertaken. The results of 172 consecutive operations for thoracoabdominal aortic aneurysm were analysed retrospectively. Hospital mortality rate was 10.5%. Temporary postoperative haemodialysis was necessary in 10.4% of cases and paraplegia occurred in 8.2%. The mean (s.e.) overall cumulative 2-, 5- and 10-year observed survival rate was 76(3.4), 53(4.5) and 19(7)%, respectively while expected survival of a background population at 2, 5 and 10 years was 94%, 85% and 71%, respectively. Reoperation for an early (<7 days) or late (>7 days) aortic event was necessary in 31 patients. If performed electively, the hospital mortality rate for late aortic reoperation was only 7% but at emergency reoperation, hospital mortality rate was 100%. Copyright © 1996 The International Society for Cardiovascular Surgery.

EEG analysis is indicated in those cases in which cerebral ischemia may arise from procedures performed during cardiac surgery. The EEG is extremely sensitive to brain dysfunction [1] caused, for instance, by cerebral hypoperfusion or changing metabolism caused by different anaesthetics [2, 3]. Due to its sensitivity, the EEG provides general information concerning the condition of the patient involved. Observing the EEGs during surgery remains a hazardous task because of the enormous amount of EEG information generated from several cases simultaneously. It is obvious that automatic analysis is essential to interpret this information within the limited period of the surgical procedure. Automatic analysis of the EEG during cardiac surgery is focussed on three hallmarks. First is detection of brain dysfunction related to anaesthesiological and surgical procedures with the shortest possible delay so that its cause can be discovered and the efficacy of the course of action can be checked. Second, it is essential to have a built-in warning/alarm system to indicate when the margins of safety have been reached. Automatic analysis without such a system is useless and brings one no further than conventional strip chart recording. Such a warning system is based on the experience of the clinical neurophysiologist and can be considered an artificial intelligence system. The third is documentation of brain function in relationship to all other parameters being monitored; this brings up its capabilities for evaluating the impact of new anaesthesiological and surgical procedures on brain function in this fast developing field.

Le monitorage par Doppler trans-crânien (DTC) et electro-encephalogramme (EEG) fournit au cours de l'endarteriectomie carotidienne des informations continues sur l'activite electrique du cortex cerebral, la velocite du flux dans l'artere cerebrale moyenne homolaterale et la survenue eventuelle de micro-embolies. Nous avons etudie de facon prospective 130 endarteriectomies carotidiennes realisees sous monitorage du DTC et de l'EEG. Nous avons trouve au cours du clampage carotidien une excellente correlation entre les asymetries de l'EEG et la diminution du flux dans l'artere cerebrale moyenne (p < 10 −6 au test t de Student). Des micro-embolies ont ete decelees au cours de l'intervention chez 80 malades

EEG recordings from 230 carotid endarterectomies performed with an automatic EEG monitoring system were reviewed with the purpose of establishing the exact relation between EEG changes and intraoperative stroke. Patients were selectively shunted, based on the EEG changes occurring after carotid cross-clamping. Transient EEG asymmetry was not associated with intraoperative stroke. Only persisting EEG asymmetry reflected intraoperative major stroke, expressed by a positive predictive value of 0.50, but also in terms of specificity (0.99), sensitivity (0.80) and diagnostic gain (47.8%) of the EEG; minor strokes could not be detected with EEG monitoring. Analysis of the time course of the persisting asymmetry confirmed the thrombo-embolic origin of the majority of the major strokes.

The prognosis in carotid disease is extremely variable and is influenced by the availability of collateral circulation. This study investigates the possibility of recognising patients with a poor collateral potential by using non-invasive tests. Preoperative OPG and EEG were compared with intraoperative EEG during test clamping in 208 carotid endarterectomies. Clamping ischaemia occurred in 29 patients (14%). Preoperative EEG had a sensitivity of 62% and a specificity of 82%. OPG showed a sensitivity of 96% and a specificity of 54%. Combined OPG and EEG resulted in a sensitivity of 93% and a specificity of 73%. Both tests are safe and easy to perform and interpret. These techniques can be used to identify those patients with carotid stenosis who have an increased risk of stroke due to a poor collateral circulation and may help to refine the indications for carotid endarterectomy.

The combined approach of extracranial arterial lesions in patients undergoing open heart surgery decreases the high cardiac and neurological morbidity and mortality presented by patients operated sequentially. Besides the anatomically sound simultaneous approach of arch lesions and heart surgery, both to be operated by median sternotomy, the authors present their criteria used in the selection of neurologically symptomatic and asymptomatic patients with carotid and vertebral disease to be operated simultaneously. Results in 17 personal cases are presented.

Bilateral one stage carotid endarteriectomy was performed in 11 patients presenting with bilateral symptomatics stenoses without neurological nor cardiac major complications. We only found one such experience in the literature (1). The choice of a simultaneous procedure is based solely on electroencephalogram analysis and on the residual pressure after the test of carotid occlusion; the side where occlusion is tolerated and/or where the residual pressure is highest, is operated first. This simultaneous bilateral procedure carries the theoretical risk of ischemia. It has the advantage of decreasing the cardiac complications and the risk of neurological deficit and at the same token avoids intercurrent controlateral thrombosis and recurrent symptoms between two non-simultaneous procedures. In cases of symptomatic lesions, the indication of surgery is evident; for asymptomatic lesions we only consider a simultaneous procedure in special cases where there exists a threat of neurological complications.