BACKGROUND:We sought to determine whether location of the second internal thoracic artery (ITA) graft used for bilateral ITA grafting affects mortality and morbidity of patients with 3-system coronary artery disease and to identify factors associated with second ITA location. METHODS AND RESULTS:From January 1972 to June 2006, 3611 patients with 3-system coronary artery disease underwent bilateral ITA grafting with one graft anastomosed to the left anterior descending system and the second to either the circumflex (n=2926) or right coronary artery (n=685) system. Follow-up was 9.2+/-7.2 years. Propensity score methodology was used to obtain risk-adjusted outcome comparisons between patients with the second ITA to circumflex versus right coronary artery. Hospital mortality (0.34% versus 0.58%; P=0.4), stroke (0.96% versus 0.88%; P=0.8), myocardial infarction (1.3% versus 0.73%; P=0.2), renal failure (0.44% versus 0.29%; P=0.6), respiratory insufficiency (3.5% versus 3.8%; P=0.7), and reoperation for bleeding (3.4% versus 3.2%; P=0.8) were similar in patients who received the second ITA to circumflex or right coronary artery and remained similar after propensity score adjustment. Late survival (86% versus 87% at 10 years) was also similar. Despite this, there was a gradual decline in ITA to right coronary artery grafting. CONCLUSIONS:Contrary to prevailing wisdom that the second ITA graft should be anastomosed to the next most important left-sided coronary artery in 3-system coronary artery disease, it may be placed to either the circumflex or right coronary artery system with similar early and late outcomes.

To evaluate the early results of mitral valve reconstruction for mitral insufficiency, 117 consecutive cases were analyzed. Sixty-four (57.7%) of the patients were men, and the mean age was 60 13 years (range 18 to 85). Eighty-nine (76%) of the patients were in NYHA functional class III or IV preoperatively. The cause of the mitral disease was degenerative in 94 (80%) and rheumatic in 13 (11%) patients. Isolated mitral valve repair was performed in 56 patients (47.9%); the remainder underwent associated procedures that included myocardial revascularization in 38 (32.5%). Ninetynine (85%) underwent a ring annuloplasty but in only seven (6%) was this the only repair technique. Resection of the posterior leaflet was performed in 41 (35%). There were five operative deaths (4.3%); one (1.8%) occurred after isolated repair and four (6.5%) after repair with associated procedures. All deaths occurred in patients greater than 65 years of age who were in NYHA functional class III or IV. Mean follow-up was 13.5 months (range 1 to 62). Two year actuarial survival was 90.6%. Three patients required reoperation (incidence of 2.5% per patient-year). Two patients sustained embolic events (incidence of 1.6% per patient-year). There were no anticoagulant-related complications. After surgery, 100 survivors (96.2%) were in NYHA functional class I or II. Circulation 74 (suppl I), I-82, 1986. AFTER OBSERVING the anatomic changes found in patients with mitral insufficiency, Carpentier' reported surgical techniques designed to correct specific anatomic abnormalities.2' His experience with these techniques in 1421 cases of mitral valve repair was recently reported.4 There have been only a few reports5'8 of patients operated on in North America by these techniques. Concern has been expressed that they might not be applicable to patients with the types of disease found in North America, and therefore might not result in a similar operative mortality rate or acceptable reoperation rate. To address these questions, one institution's experience was evaluated to determine the early results with these operative techniques. Materials and methods Patients. Patients selected for valvuloplasty were those who, at the time of surgery, were found to have anatomic defects suitable for the procedure. They were not excluded because of age, poor ventricular function, or concurrent coronary artery or valve disease. One hundred seventeen consecutive patients undergoing mitral valve reconstruction for mitral insufficiency from January 1980 through July 1985 were studied. The chronologic distribution of cases is shown in figure 1. The incidence of mitral valve From the Departments of Thoracic and Cardiovascular Surgery and Biostatistics, The Cleveland Clinic Foundation, Cleveland. Address for correspondence: Delos M. Cosgrove, M.D., The Cleveland Clinic Foundation, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Ave., Cleveland, OH 44106. 1-82 repair has increased sharply. In the first half of 1985, 30% of all mitral valve operations were reconstructions (figure 2). Mean age of the patients was 60 + 13 years (range 18 to 85). The series included 35 patients more than 70 years old. There were 64 men (54.7%) and 53 women (45.3%). Eighty-nine patients (76.6%) were in NYHA functional class III or IV. Mitral insufficiency was secondary to degenerative disease in 94 patients (80. 1 %). Table 1 shows the distribution of causes of mitral insufficiency. Statistical method. Analyses for statistical significance were done with chi-square tests. The Kaplan-Myer method was used for calculating actuarial survival for hospital survivors. Surgical procedure. Isolated mitral valve repair was carried out in 56 patients (47.9%), while repair with associated procedures was undertaken in 61 patients (52.1%). Myocardial revascularization accompanied mitral valve repair in 38 patients (35.5%). The associated surgical procedures are listed in table 2. Multiple surgical techniques were used to obtain mitral valve competence. A Carpentier annuloplasty ring was used in 99 patients (85%), but in only seven patients (6%) was annuloplasty the sole surgical technique used to achieve mitral competence. A total of 193 repair techniques were employed in 117 patients (table 3). Patients routinely received the anticoagulant warfarin for 3 months.

Over the last 20 years, operative mortality has decreased and late survival has improved for patients with chronic stable angina who have coronary artery bypass surgery. However, this favorable trend may not continue because the operation is now extended to elderly and high-risk patients. The most powerful predictors of operative mortality include indexes of left ventricular function, age, and the number of associated medical conditions. Female gender, severity of angina, and extent of coronary artery disease appear to be predictors of operative mortality in some series but not in all. Indexes of left ventricular dysfunction remain the most powerful predictors of late death, but the extent of coronary disease, older age, and presence of associated diseases (including noncardiac vascular disease) remain important determinants. Analyses of the randomized trials and registry studies reveal a consistent trend: in patients at high risk on the basis of clinical, functional, and anatomic characteristics, coronary artery bypass surgery prolongs survival in comparison with medical therapy alone. In patients determined to be at low risk, medical therapy is initially recommended with the realization that revascularization may be necessary subsequently if symptoms worsen or the severity of ischemia increases. (Circulation 1989;79(suppl I):I-46-I-59)

Objective: Our objectives were to document the preoperative and postoperative functional status of patients undergoing coronary artery bypass grafting, to examine factors that influence functional recovery, and to determine whether gender differences exist in the preoperative and postoperative functional status with the Duke Activity Status Index.Methods: One thousand eight hundred twenty-five patients undergoing isolated coronary artery bypass grafting had baseline and follow-up quality-of-life surveys. Mean follow-up from baseline to postoperative Duke Activity Status Index was 8.0 months for women and men. The influence of 47 variables, in addition to baseline scores on postoperative functional status, was examined with logistic ordinal modeling. An ordinal model for the follow-up score was determined by means of backward selection, with variables retained if they satisfied the criterion of a P value of less than .05.Results: Median baseline Duke Activity Status Index scores (women, 21.5; men, 32.2; P < .001) and first follow-up scores (women, 42.7; men, 58.2; P < .001) were lower in women than in men. Patients who were older and those who had chronic obstructive pulmonary disease, myocardial infarction, stroke, diabetes, vascular disease, postoperative serious infection, and return to the operating room had lower postoperative scores. After adjusting for these factors, women still had lower follow-up scores (odds ratio for men, 2.1 [95% confidence interval, 1.7-2.6]; P < .001).Conclusions: A number of preoperative factors, operative variables, and postoperative events are associated with functional recovery after coronary revascularization. In addition, female gender is associated with more postoperative functional impairment after adjusting for these perioperative variables.

Objectives. We sought to determine the clinical, angiographic, treatment and outcome correlates of the intermediate-term cost of caring for patients with suspected coronary artery disease (CAD).Background. To adequately predict medical costs and to compare different treatment and cost reduction strategies, the determinants of cost must be understood. However, little is known about the correlates of costs of treatment of CAD in heterogenous patient populations that typify clinical practice.Methods. From a consecutive series of 781 patients undergoing cardiac catheterization in 1992 to 1994, we analyzed 44 variables as potential correlates of total (direct and indirect) in-hospital, 12- and 36-month cardiac costs.Results. Mean (+/-SD) patient age was 65 +/- 10 years; 71% were men, and 45% had multiple vessel disease. The initial treatment strategy was medical therapy alone in 47% of patients, percutaneous intervention (PI) in 30% and coronary artery bypass graft surgery (CABG) in 24%. The 36-month survival and event-free (death, infarction, CABG, PI) survival rates were 89.6 +/- 0.2% and 68.4 +/- 0.4%, respectively. Median hospital and 36-month costs were $8,301 and $28,054, respectively, but the interquartile ranges for both were wide and skewed. Models for log, costs were superior to those for actual costs. The variances accounted forby the all-inclusive models of in-hospital, 12- and 36-month costs were 57%, 60% and 71%, respectively. Baseline cardiac variables accounted for 38% of the explained in hospital costs, whereas in hospital treatment and complication variables accounted for 53% of the actual costs. Noncardiac variables accounted for only 9% of the explained costs. Over time, complications (e.g., late hospital admission, PI, CABG) and drug use to prevent complications of heart transplantation became more important, but many baseline cardiac variables retained their importance.Conclusions. 1) Variables readily available from a comprehensive cardiovascular database explained 57% to 71% of cardiac costs from a hospital perspective over 3 years of care; 2) the initial revascularization strategy was a key determinant of in hospital costs, but over 3 years, the initial treatment become somewhat less important, and late complications became more important determinants of costs. (C) 1998 by the American College of Cardiology.

In each of the first three decades of myocardial revascularization, conventional treatment has been revised completely. This lecture comments on three areas of discovery that have shaped the evolution of myocardial revascularization: science, technology development, and revascularization. The discoveries in all three areas are inexorably interrelated. The single greatest lesson learned so far is that conduit performance carries more prognostic weight than any other factor. We have observed that vein graft atherosclerosis is predictable, and that the first-generation lipid lowering drugs have a favorable effect in patients who achieve marked LDL reduction. Biologically better revascularization begins with use of the internal thoracic artery for grafting to the anterior descending coronary artery. As the results of internal thoracic artery grafting are widely reported, arterial bypass revascularization has expanded, notably by radial and gastroepiploic arteries. The results of bilateral internal thoracic artery grafting are discussed, including large-scale registry results of internal thoracic artery usage in the United States. The internal thoracic artery is significantly underutilized. Diabetes affects both endoluminal and surgical revascularization. The new pharmacology in cardiology interventions shows promise in diminishing restenosis and thrombosis even in diabetic patients. Conversely, extended internal thoracic artery grafting may also benefit diabetic patients. Now we are entering a new age of minimally invasive coronary surgery. We have passed through the early stages of mini-thoracotomy, and we are moving on to access through 1-cm ports, intrathoracic cannulation, antegrade and retrograde myocardial protection, and computer guided three-dimensional vision and instrumentation. The potential for robotic control adds greater precision, ease of use, and safety. This new technology will be integrated with diagnostic information, intraoperative monitoring, anesthesia and perfusion data, cost accounting, and surgical note transcription. The operating room of the future will package intraoperative information and is adaptable to all surgical specialties. The future of coronary artery surgery will depend on minimally invasive techniques, all-arterial grafting, and selective lipid modification to reduce progressive atherosclerosis. The conclusion of this decade marks the end of the beginning. The new generation of cardiothoracic surgeons will share in an array of technology and research unmatched in previous decades. © 1998 Elsevier Science B.V. All rights reserved

Objective: In small to moderate doses, oxycodone has similar analgesic efficacy to morphine with fewer side effects. The present study evaluated the pharmacokinetics and dynamics of high doses of oxycodone during anesthesia for primary coronary artery bypass grafting.Design: A randomized, prospective clinical evaluation.Setting: A major Scandinavian university clinic.Participants: Two groups with 10 patients each were studied.Interventions: Invasive hemodynamics, echocardiograms, and electrocardiograms were monitored. Oxycodone kinetics, histamine liberation, and plasma cortisol levels were measured. Anesthesia was induced with 1.0 mg/kg of oxycodone and, thereafter, in a random order, maintained with a continuous infusion of oxycodone at a rate of either 0.5 mg/kg/h (group OX 0.5, 10 patients) or 1.0 mg/kg/h (group OX 1.0, 10 patients). An additional bolus dose of 0.5 mg/kg (OX 0.5) or 1.0 mg/kg (OX 1.0) of oxycodone was given before the incision. Enflurane was administered according to hemodynamic criteria.Measurements and Main Results: The induction of and the course of anesthesia were hemodynamically stable in all patients. Enflurane was given to every patient. The mean total doses of oxycodone were 3.5 mg/kg (OX 0.5) and 6.2 mg/kg (OX 1.0). The median t1/2 of oxycodone varied from 5.1 to 5.9 hours. No hemodynamic differences were found between the groups. No histamine liberation was detected. During anesthesia, the predominant waves in the EEG were θ- and δ-waves. The mean times to awakening were 3.8 hours and 7.0 hours in the groups OX 0.5 and 1.0, respectively. All patients were intubated until the first postoperative morning. No recall of awareness was reported.Conclusion: A combination of oxycodone and enflurane provides hemodynamically stable anesthesia. No advantages were gained with the higher dose. Elimination of oxycodone was slower than reported previously.

sient hypotension, and 2 had a significant QRS widening with induction of a transient complete left bundle branch block in I. Electrocardiographic QRS intervals measured immediately after conversion to sinus rhythm were unchanged compared with baseline for placebo, but for flecainide and propafenone a mean lengthening of 25% and 21% occurred, respectively. The efficacy of propafenone and flecainide in converting recent-onset AF to sinus rhythm has been studied, but no direct comparison between these 2 drugs administered as acute, oral loading doses in a placebocontrolled study has been previously reported. The present study confirms that acute oral antiarrhythmic drug loading is simple and effective. Because spontaneous conversion of AF to sinus rhythm may occur in 39% to 48% of patients within 8 hours,3 we believe a placebo group is essential to assess drug efficacy. The use of class 1C antiarrhythmic drugs like propafenone or flecainide carries the risk of inducing atria1 flutter with a fast ventricular response,5,6 and we observed this. However, spontaneous atria1 flutter with 22: 1 AV conduction ratio and a heart rate of 1150 beats/min occurs relatively often, even with placebo, especially during the time preceding conversion to sinus rhythm. The negative inotropic effect of class 1C drugs mandates that patients with heart failure or significant cardiac dysfunction are not treated with these agents. The negative chronotropic response (long pause at the time of conversion from AF to sinus rhythm) was observed with both drugs but was not associated with an adverse outcome.

did not seek personal monetary reward for his extraordinary invention. He readily shared his work with other surgeons seeking to develop cardiopulmonary bypass, and, in later years, as editor of the Annals of surgery, disdained to publish ’case reports’, which is highly ironic for the author of one of the most significant case reports of the 20th century. Ultimately, Gibbon was not satisfied with his accomplishments and felt that he could have or should have done more.

Reoperative coronary artery bypass grafting secondary to saphenous vein graft (SVG) stenosis is a mushrooming problem. The internal thoracic artery graft (ITA) provides superior long-term patency, but its flow is limited and may be inadequate to meet large myocardial demands. To evaluate the efficacy of the ITA as a replacement conduit for a stenotic SVG, 387 consecutive patients undergoing reoperative bypass grafting from 1985 to 1990 with a stenotic SVG to a totally obstructed left anterior descending coronary artery (LAD) were analyzed. The patients were divided into four groups according to the management of the previously placed SVG. Group I (n = 155) underwent graft replacement with a new SVG. Group II (n = 90) received an ITA with the old SVG left intact. In group III (n = 37), an ITA was placed to the LAD with an SVG to the diagonal (old graft interrupted). Group IV (n = 104) had an ITA only to the LAD (old graft interrupted). There were 14 deaths (3.6%). Mortality rate was 7.9% for group IV and 2.1% for groups I through III (p = 0.01). Multivariate analyses identified advancing age (p = 0.001), ITA only (p = 0.001), and female sex (p = 0.04) as independent predictors of operative mortality. Evidence of hypoperfusion in the distribution of the LAD was present in 19 patients, all of whom were in group IV (18.9%). Predictors of hypoperfusion were moderate/severe left ventricular function (p = 0.02) and ITA to the LAD with interruption of the old graft (p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of myocardial protection with a single aortic crossclamp and blood cardioplegia was evaluated in 819 consecutive patients stratified for preoperative condition by means of a new clinical risk scoring system. A protocol using either antegrade or antegrade/retrograde blood cardioplegia was compared with antegrade crystalloid cardioplegia in 2582 similar, consecutive, and concurrent patients. In the blood cardioplegia cohort, 97 (11.8%) patients had 129 complications compared with 407 (15.8%) patients and 675 complications in the crystalloid cardioplegia group (p = 0.006). In high-risk patients, combined antegrade/retrograde cardioplegia significantly reduced myocardial infarction, stroke, and respiratory and wound complications. Despite the significantly longer aortic crossclamp time required for blood cardioplegia, patients undergoing crystalloid cardioplegia were 1.7 (95% confidence interval 1.3, 2.1) times more likely to have a morbid event. Time in the intensive care unit, length of hospitalization, and length-of-stay outlier status were significantly decreased in the blood cardioplegia compared with the crystalloid cardioplegia group. The net savings in hospital cost amounted to $2196 per case. When compared separately with crystalloid cardioplegia, combined antegrade/retrograde blood cardioplegia accounted for most of the morbidity reduction by significantly reducing perioperative myocardial infarction, wound complications, and length of stay in patients having reoperations. Antegrade/retrograde blood cardioplegia did not influence 1-year survival or event-free survival, even when risk was considered.

As the ages of patients undergoing cardiac operations have increased, noncardiac causes of death have increased. To identify these causes of death, we analyzed the autopsy findings in 221 patients undergoing myocardial revascularization or valve operations between 1982 and 1989. Mean age was 65.6 ± 9.5 years and the range was from 32 to 94 years; 130 patients (58.8%) were male. Autopsies were complete in 129 patients (58.4%) and limited to the chest and abdomen in the remainder. Embolic disease was identified in 69 patients (31.2%). Atheroemboli or abnormalities consistent with atheroemboli were identified in 48 patients (21.7%). Fourteen patients had thromboembolism and 7 had disseminated intravascular coagulation. The prevalence of atheroembolic disease increased dramatically from 4.5% in 1982 to 48.3% in 1989 (p = 0.001). Atheroembolic disease was found in the brain in 16.3% of patients, spleen in 10.9%, kidney in 10.4%, and pancreas in 6.8%. Thirty (62.5%) of the 48 patients had multiple atheroembolic sites. Atheroemboli were more common in patients undergoing coronary artery procedures (43/165; 26.1%) than in those undergoing valve procedures (5/56; 8.9%) (p = 0.008). There was a high correlation of atheroemboli with severe atherosclerosis of the ascending aorta. Atheroembolic events occurred in 46 of 123 patients (37.4%) with severe disease of the ascending aorta but in only 2 of 98 patients (2%) without significant ascending aortic disease (p < 0.0001). Forty-six of 48 patients (95.8%) who had evidence of atheroemboli had severe atherosclerosis of the ascending aorta. There was a direct correlation between age, severe atherosclerosis of the ascending aorta, and atheroemboli. Incremental risk factors for atheroemboli are peripheral vascular disease and severe atherosclerosis of the ascending aorta. (J Thorac Cardiovasc Surg 1992;103:1104-12)

We tested the efficacy and safety of aprotinin in 169 patients undergoing isolated reoperative myocardial revascularization. Patients were randomly assigned to high-dose aprotinin, low-dose aprotinin, or placebo treatment groups in a double-blind, placebo-controlled study. Treatment groups did not differ significantly with respect to age, sex, red cell mass, number of grafts, use of internal thoracic artery, or incidence of preoperative aspirin therapy. Patients treated with aprotinin had a significant reduction in postoperative chest tube drainage (720 +/- 753, 866 +/- 1,636, and 1,121 +/- 683 mL, respectively, for high-dose aprotinin, low-dose aprotinin, and placebo; p < 0.001). Transfusion requirements were reduced in aprotinin-treated patients (2.1 +/- 4.2, 4.8 +/- 11.8, and 4.1 +/- 6.2 units for high-dose, low-dose, and placebo, respectively, p < 0.001). A similar reduction in chest tube drainage and transfusion requirements was seen in patients using aspirin preoperatively. Q-wave myocardial infarctions were increased in the aprotinin subgroups (17.5%, 14.3%, and 8.9% for high-dose, low-dose, and placebo groups; not significant). Acute vein graft thrombosis was found in six of 12 vein grafts studied at postmortem examination in patients receiving aprotinin but not in any of five grafts in patients receiving placebo. We conclude that aprotinin is extremely effective in reducing bleeding and transfusion requirements and may increase the risk of graft thrombosis.

The occurrence and course of supraventricular rhythm and atrioventricular conduction disturbances were retrospectively compared in 206 patients with isolated mitral valve disease undergoing either valve replacement or ring annuloplasty (mitral repair) between January 1, 1985 and December 31, 1986. The replacement and repair groups were the same size and had approximately equal numbers of patients in sinus rhythm and atrial fibrillation preoperatively. The type of mitral valve operation did not affect the short-term outcome in terms of cardiac rhythm. For both groups, the incidence of patients crossing from sinus rhythm to atrial fibrillation and vice versa on the pre-discharge electrocardiography was equal, and both groups had a low incidence of clinically significant atrioventricular block.