J Cardiovasc Surg
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The operative mortality and morbidity in patients with severe left ventricular dysfunction who undergo coronary artery bypass grafting (CABG) remain high. The low ejection fraction is the major risk factor for operative mortality. However, ejection fraction (EF) alone may not necessarily be an accurate predictor of operative mortality. We studied the correlation between indices of left ventricular volume and operative mortality. One thousand patients undergoing isolated coronary bypass operations were divided into three groups according to their preoperative ejection fraction. Fifty patients (group I) had severe left ventricular dysfunction (EF < or = 0.3), 56 patients (group II) had moderately left ventricular dysfunction (0.3 < EF < or = 0.4) and 894 patients (group III) had good left ventricular function (EF > 0.4). We analyzed the relationship between hospital mortality and left ventricular volume in 106 patients with an EF < or = 0.4. ⋯ Cardiac index was not significantly different among the three groups. The left ventricular end-diastolic pressure (LVEDP) and mean pulmonary artery pressure in groups I an II were higher than those in group III. The left ventricular end-diastolic volume (LVEDV) was 146 +/- 44 ml/m2 in Group I, 112 +/- 31 ml/m2 in Group II and 82 + 30 ml/m2 in Group III, respectively (Group I versus II, p < 0.05, Group I and II versus III, p < 0.01). The left ventricular end-systolic volume (LVESV) was 111 +/- 38 ml/m2 in Group I, 72 +/- 21 ml/m2 in Group II and 30 +/- 14 ml/m2 in Group III, respectively (Group I versus II, p < 0.05, Group I and II versus III, p < 0.01). The LVEDV and LVESV were higher in Group I than in Group II and both in Groups I and II were higher than in Group III. The hospital mortality of any cause before discharge was 8.0% (4/50) in Group I, 3.6% (2/56) in Group II, and 2.0% (18/894) in Group III. The mortality in Group I was higher than that in Group III, but the mortality between Groups I and II was not different. We assessed correlations between large left ventricle with left ventricular dysfunction and operative mortality in 106 patients with ejection fractions of < or = 0.4. The hospital mortality in patients with both under fraction 0.4 and an LVESV > or = 140 ml/m2 was 50% (4/8). This rate was higher than in patients with an LVESV between 80 and 140 ml/m2 (1.8%, 1/55) (p = 0.0006) and an LVESV less than 80 ml/m2 (2.3%, 1/43), (p = 0.0013). The hospital mortality in patients with an LVEDV > or = 200 ml/m2 was 67% (4/6). It was also higher than that in patients with an LVEDV between 200 and 120 ml/m2 (1.7%, 1/58), (p = 0.0001), and an LVEDV less than 120 ml/m2 (2.4%, 1/42), (p = 0.0004). We conclude that patients with a low ejection fraction and an elevated LVESV or LVEDV are at increased risk for hospital death following CABG.
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The intra-aortic balloon pump (IABP) is an established additional support to pharmacologic treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The physiologic effect of IABP are: increased coronary perfusion and decreased left ventricular outflow impendance. The effects of preoperative IABP are not established. ⋯ The mean ICU stay was 2.1 +/- 0.9 days. The first part of this study identified riskfactors for mortality after CABG and in the second series the efficacy of preoperative IABP treatment in "high-risk" patients was demonstrated. Preoperative IABP support in these patients seems also cost efficient due to lower mortality and shorter stay in intensive care unit in this group of patients.
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Randomized Controlled Trial Comparative Study Clinical Trial
Pulsatile and nonpulsatile extracorporeal circulation using Capiox E terumo oxygenator: a comparison study with Ultrox and Maxima membrane oxygenators.
An open randomised, prospective study was undertaken on 90 patients who underwent routine myocardial revascularization. The aim of the study was to demonstrate that the Capiox E polypropylene fiber membrane oxygenator with a conventional single pulsatile/nonpulsatile blood pump for cardiopulmonary bypass (CPB) was comparable in performance to that of the Maxima and the Ultrox membrane oxygenators using a double pump system. The patients were divided into six groups according to perfusion mode and oxygenator type. ⋯ The FiO2 was higher in the Capiox E groups 0.77 (PP) and 0.88 (NP) compared to Maxima/PP (0.66), /NP (0.65) and Ultrox/PP (0.64), /NP (0.63). Reciprocally, the venous saturation was higher in the Ultrox and Maxima groups compared to Capiox E at end of CPB. The study demonstrated that the CapioxE oxygenator with a single blood pump system can compare to the Maxima and Ultrox oxygenators with a double blood pump for CPB with regard to blood handling, oxygenation and fluid balance in routine cardiac surgery.
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Coronary artery bypass grafting (CABG) is the most common procedure performed in adult cardiovascular surgery today. In our Department of Surgery at Baylor College of Medicine, we have experienced, as have most large programs, a trend to older patients, more comorbidity, worse ventricular function, and more redo CABG procedures. ⋯ Data for multiple arterial grafts is still evolving and conduit choice for other than the IMA to LAD graft is often debated. The purpose of this article is to review the current literature on conduit choice and to allow a rational, data driven approach to graft choice.
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Comparative Study
Clinical importance of measuring coronary graft flows in the revascularized heart. Ultrasonic or electromagnetic?
In the past, routine coronary graft flow measurement at the end of coronary artery bypass grafting (CABG) was not universally adopted by cardiac surgeons due to the lack of reliable flow measurement techniques. The purpose of this study was to investigate the efficacy of ultrasonic and electromagnetic techniques in coronary graft flow measurements and to determine the relationship, if any, between intraoperative ultrasonic or electromagnetic coronary graft flows and postoperative early clinical outcome. ⋯ The ultrasonic flowmeter is well-suited for intraoperative assessment of arterial and venous coronary graft flows at the completion of CABG. There is a real potential for using intraoperative graft flow values to predict early outcome after coronary bypass.