Objective: Multiple strategies to achieve some degree of myocardial revascularization are available. In some, less complete revascularization is accepted to limit invasiveness. To examine the issues of incomplete revascularization, we assessed the long-term impact of additional non–left anterior descending coronary artery stenoses in patients undergoing only grafting of the left internal thoracic artery to the left anterior descending coronary artery. Methods: A total of 2067 patients underwent primary isolated grafting of the left internal thoracic artery to the left anterior descending coronary artery from 1971 to 1997. Of these, 26% and 13% had 2- and 3-system disease, respectively. Multivariable analyses of survival and reintervention were performed in the hazard function domain for 27,683 patient-years of follow-up (mean 14 ± 6.7). Results: Survival was 99%, 88%, and 62% at 1, 10, and 20 years. Right coronary artery or left circumflex system disease of 50% or more (P =.02) and particularly high-grade (≥70%) left circumflex (P =.01) and proximal right coronary artery disease (P =.01), as well as any degree of left main trunk stenosis (P <.0001), were associated with reduced long-term survival. Compared with 75% 20-year survival in patients with no non–left anterior descending disease, those with either left circumflex or left main trunk disease experienced a 44% survival, and those with proximal right coronary artery disease, 42%. The most common stated reason for incomplete revascularization was small vessel size. Freedom from reintervention was 89% and 65% at 10 and 20 years, respectively. High-grade left main trunk disease, but, in contrast, mid or distal disease of the right coronary artery, and not left circumflex disease, were risk factors for reintervention. Conclusions: These findings call into question the long-term appropriateness of interventions whose strategy includes leaving unrevascularized segments in territories not in the distribution of the left anterior descending coronary artery. (J Thorac Cardiovasc Surg 2000;120:173-84)

Objective: Intraoperative myocardial contrast echocardiography was used to determine whether the identification of regional myocardial flow patterns during revascularization could predict myocardial contractile function immediately after separation from cardiopulmonary bypass (CPB) and at 1 month after coronary artery bypass grafting (CABG) surgery.Design: A prospective, open-labeled, longitudinal analysis.Setting: Two independent university hospitals.Participants: Twenty patients, during and up to 1 month after CABG.Interventions: The contrast agent Albunex (Mallenckrodt Medical, Inc, St Louis, MO) was injected into the aortic root during CPB.Measurements and Main Results: Myocardial contrast echocardiography opacification of flow was graded from intraoperative transesophageal echocardiographic images of the left ventricle in the short-axis, midpapillary view. The same myocardial images were also evaluated for regional wall motion abnormalities at 15, 30, and 60 minutes, 24 hours, 5 to 8 days, and 1 month after CPB. Logistic regression analysis was used to analyze the flow scores and regional function data from identical segments. Regional flow represented by contrast enhancement was assessed in 70% of the myocardial regions (55 of 80 possible segments; 95% confidence interval [CI], 61 to 76). Flow was more easily evaluated in the posterior region (95%) than in the anterior (70%) or septal regions (60%), and least likely evaluated in the lateral regions (50%). Regional wall motion was scored in 84% of the myocardial regions (469 of 560 possible regions). Function (segmental wall motion) was assessed in all regions with equal success. Segmental function and flow scores were matched to the same regions 66% of the time (53 of 80 possible series; 95% CI, 55 to 76). Regional myocardial contrast flow patterns did not predict myocardial function at 15, 30, or 60 minutes after separation from CPB. However, contrast opacification of flow did predict regional myocardial function at 1 week (p less than or equal to 0.05) and at 1 month (p less than or equal to 0.01) after CABG surgery. The probability that myocardial function would be normal at 1 month was 0.62 when intraoperative flow opacification was abnormal and 0.98 when flow opacification was normal. For patients with normal flow, the estimated odds of having normal myocardial function were 3.33 times those of patients with abnormal flow at 1 week (odds ratio, 3.33; 95% CI, 1.09 to 10.19) and 18.5 times those of patients with abnormal flow at 1 month (95% CI, 2.44 to 140.48).Conclusion: Intraoperative application of myocardial contrast echocardiography to determine regional flow patterns after revascularization may help differentiate conditions of left ventricular systolic dysfunction immediately after separation from CPB for CABG surgery and appear to predict myocardial function at 1 month. Copyright (C) 1998 by W.B. Saunders Company.

J Thorac Cardiovasc Surg 1998;116:683-8.

The reuse of disposable devices is a potential source of significant cost savings to hospitals. Venous and arterial perfusion cannulae under new and reused conditions were selected to identify the clinical, safety, technical, logistic, and economic issues that must be addressed to realize these savings. Single- and dual-stage venous and arterial cannulae from two manufacturers were tested when new, after initial clinical use, and after a single clinical use plus up to nine simulated reuses. Reuse was simulated by end-to-end bending, coupling and uncoupling the connectors, and by two 1-hour soaks in plasma at 4 degrees C and 40 degrees C, respectively. Cannulae were decontaminated and then sterilized by a peracetic acid based liquid chemical sterilization system following each use/reuse. Sterilization was validated by eliminating Bacillus subtilis spores from the cannulae on each of five consecutive cycles. Cannulae were tested for physical changes, functional integrity, biocompatibility, and in vivo performance in sheep. A cost minimization analysis was also performed. No clinically important differences were found between new and reused cannulae, even after nine simulated reuses. Mechanical changes were less than 20% on all variables studied and were undetectable by experienced cardiac surgeons in selective evaluation. Sterilization was successfully achieved. Reusing cannulae for times would reduce the cost per procedure from $53 to $19 (64%). Perfusion cannulae tested can be safely and efficaciously used five times. This study suggests that reuse would result in a small incremental savings; however, with more expensive devices and higher-volume sterilization procedures, the savings could be exponentially greater. Although this study demonstrates that it may be technically feasible and cost-effective to reuse disposable cannulae, the U.S. Food and Drug Administration does not sanction the reuse of disposable cannulae.

Objective: To test the safety and report on limiting technical considerations, including optimal dosing of Albunex (Molecular Biosystems, Inc, Mallinckrodt Medical, St. Louis, MO) for myocardial opacification after intra-aortic root injections during cardiac surgery.Design: This was a prospective randomized study with a control group who did not receive Albunex and a group who received intra-aortic root injections of Albunex.Setting: Multicenter (two) independent university hospitals.Participants: 32 patients scheduled for elective coronary artery bypass surgery were evaluated after individual informed consent was obtained.Interventions: 2 to 8 mt of Albunex were injected before and after coronary revascularization.Measurements and Main Results: Quality of enhancement in each of four regions of the left ventricle was assessed from a short-axis mid-papillary ultrasound image by three experienced observers blinded to dose. Electrocardiogram (EGG), creatine phosphokinase (CPK) (MB fraction), and hemodynamics were evaluated at baseline and throughout the study period for up to 72 hours. No differences were noted between groups with respect to preoperative and postoperative CPK enzymes (CPK-MB fraction), ECG changes, hemodynamics, requirements for separation from CPB, need for postoperative inotropes, time to extubation, and time to discharge from the intensive care unit. The average total dose of Albunex injected was 19 mL +/- 4 (0.25 mL/kg). A single dose of 4.2 +/- 1.2 mt (0.05 mL/kg) appeared to offer optimal enhancement of contrast effect for myocardial perfusion assessment.Conclusion: Albunex is safe and easy to use for myocardial opacification when administered via an antegrade cardioplegia catheter into the aortic root during CPB. Copyright (C) 1996 by W.B. Saunders Company

BACKGROUND Since 1989, New York State has disseminated comparative information on outcomes of coronary bypass surgery to the public. It has been suggested that this program played a significant role in the 41% decrease in the risk-adjusted mortality rate between 1989 and 1992. We hypothesized that some high-risk patients had migrated out of state for surgery. METHODS AND RESULTS We reviewed 9442 isolated coronary bypass operations performed from 1989 through 1993 to assess referral patterns of case-mix and outcome. Expected and risk-adjusted mortality rates were computed using logistic regression models derived from the Cleveland Clinic and New York State databases. A mortality comparison was performed using the 1980 to 1988 time period as a historical control. Patients from New York (n=482) had a higher frequency of prior open heart surgery (44.0%) than patients from Ohio (n=6046) (21.5%, P<.001), other states (n=1923) (37.4%, P=.008), and other countries (n=991) (17.3%, P<.001). They were also more likely to be in NYHA functional class III or IV (47.6% versus Ohio 42.7%, P=.037; other states, 41.2%, P=.011; other countries, 34.1%, P=.001). The expected mortality rate was thus higher than among other referral cohorts. The observed 5.2% mortality rate among these patients was significantly greater than the 2.9%, 3.1%, and 1.4% mortality rates observed for patients from Ohio (P=.004), other states (P=.028), and other countries (P<.001). These differences in outcome were not apparent between 1980 and 1988 among referrals from within the United States. CONCLUSIONS Public dissemination of outcome data may have been associated with increased referral of high-risk patients from New York to an out-of-state regional medical center.

To evaluate the function of the Carpentier-Edwards pericardial valve in the aortic position, we analyzed the results of 310 aortic valve replacements performed between 1982 and 1985. Mean age was 64.2 +/- 10.8 years (range 22 to 95 years); 190 patients (61.3%) were male patients. There were 18 hospital deaths (5.8%), and none were valve related. Follow-up of the 292 survivors was 100% complete at a mean of 7.8 +/- 2.9 years; 2290 patient-years of follow-up were available for analysis. There were 133 late deaths (45.5%). Actuarial survivals at 5 and 10 years were 82.5% and 45.9%, respectively. The 10-year actuarial freedom from events was 88.7% +/- 2.1% for thromboembolism, 90.9% +/- 1.8% for hemorrhage, 94.3% +/- 1.6% for endocarditis, and 91.2% +/- 2.6% for structural deterioration. The 153 hospital survivors 65 years of age or older had an extremely low incidence of structural valve deterioration, with only four explants and 95.5% actuarial freedom from explantation at 10 years, and a linearized rate of 0.3 +/- 0.2 per patient-year compared with 88.6% and 0.7 +/- 0.2 for patients younger than 65 years of age. Twelve valves were explanted for structural deterioration. Of these, 11 (93%) had leaflet calcification causing stenosis and one had a wear-related leaflet tear. The Carpentier-Edwards pericardial valve has a low incidence of valve-related complications. The freedom from structural valve deterioration is low at 10 years, particularly in patients 65 years of age and older.

BACKGROUND:Coronary angioplasty is frequently performed in the United States, with more than 300,000 procedures in 1990. Despite the high rate of use of the procedure, there have been few studies addressing practice patterns.METHODS AND RESULTS:From a private insurance claims data base of 5.4 million individuals, a total of 2,101 patients who underwent coronary angioplasty during 1988-1989 were identified. Using their 4,578 hospital admission records and 87,578 outpatient claim records, with an average follow-up of 332 +/- 182 days, we compared patients' outcomes and charges according to whether they had an exercise stress test before the procedure, by sex, by region of the country, and by whether the angioplasty was performed in an institution with a training program. Only 29% of the study cohort had exercise testing before angioplasty; patients in the West (p = 0.001), those undergoing multivessel angioplasty (p = 0.00001), and those whose procedures were performed at sites with training programs (p = 0.04) were more likely to have a screening test, whereas women (p = 0.008) and those with a recent myocardial infarction (p = 0.00001) were less likely to have a screening test. The average length of stay for patients without myocardial infarction as a primary diagnosis was 5.6 days, with a total hospital charge of $15,027. In follow-up, 15.1% had coronary artery bypass surgery and 15% had at least one additional angioplasty procedure; the average follow-up charges were $4,879. Charges varied according to sex, region of the country, and academic status of the angioplasty institution. Certain outcomes showed variation by region of the country and academic status of the angioplasty institution.CONCLUSIONS:The relative lack of an objective definition of myocardial ischemia and the marked variability of use of procedures according to geographic region suggest the need for further implementation of established guidelines.

In conjunction with our project in laser angiosurgery, our group has demonstrated that laser-induced auto-fluorescence can be a reliable means of distinguishing normal artery from atherosclerotic plaque. Recently a number of groups have become interested in this technique as a means of directing ablation of arterial obstructions in vivo. However, until now, diagnostic spectroscopy has been conducted almost solely on excised cadaveric tissues. As a result, questions still remain about 1) the validity of correlating cadaveric tissue fluorescence spectra with those collected in vivo, and 2) the ability to collect reliable florescence spectra from a subject as dynamic as a living patient.