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To explore the limitations of using arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions, we evaluated 195 patients with combined lesions undergoing CABG, either alone or in combination with peripheral vascular reconstruction between October 1987 to October 1990. Doppler flow and spectral analysis revealed that 14 patients (7.1%) had atherosclerotic lesions of the subclavian artery, in whom ipsilateral internal mammary artery pedicle graft was contraindicated for myocardial revascularization. Out of 195 patients, 165 patients were subjected for aortography, 18 of whom (10.9%), revealed atherosclerotic involvement of the celiac trunk, thereby contraindicating the use of gastroepiploic artery for myocardial revascularization. Thus in our experience use of arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions is limited.

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To evaluate the effectiveness of retrograde cardioplegia and reperfusion, a total of 266 patients undergoing coronary bypass surgery between Nov 1987 to Dec 1989 were divided into three groups depending on the method of cardioplegic fluid delivery and reperfusion. In group I (80 patients) antegrade cardioplegia and reperfusion was used. In group II (98 patients) antegrade and retrograde cardioplegia and antegrade reperfusion was used while in group III antegrade and retrograde cardioplegia and retrograde reperfusion was used. Myocardial functions were studied with the help of an on-line computer on the basis of mathematical model of heart before and after cardiopulmonary bypass. Biopsy specimens were collected before, during and after cardiopulmonary bypass in order to study myocardial structural changes. In group I patients there was decrease in myocardial function in the immediate post perfusion period while group II patients had considerable improvement in their myocardial function and groups III patients showed further improvement in it. Ultrastructural myocardial study revealed considerable detrimental changes in group I, minimal changes in group II and no change in group III patients. Thus in our experience retrograde cardioplegia and retrograde reperfusion with warm oxygenated blood provide maximum myocardial protection in patients with multiple coronary artery lesions.

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In the period from Jan. 1988 to Jan. 1991 operations for the formation of an aortocoronary shunt were carried out in 437 patients at the Department of Combined Affections of the Coronary and Peripheral Arteries, Bakulev Research Institute. In some cases the operation was combined with resection of a postinfarction aneurysm of the left ventricle. Cerebral complications developed in the postoperative period in 28 (6.4%) patients. Their analysis showed the prevalence of severe forms of consciousness disturbances: coma and comatose states were encountered in 85.7% of cases. The main causes of the complications were acute heart failure (64.3%) and arterial embolism (14.3%). In only one case concomitant affection of the branches of the aortic arch was found to be the main cause of the development of a transitory ischemic attack. It is concluded that the development of acute heart failure in the patients may sharply increase the incidence of neurologic complications.

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The clinico-hemodynamic and angiographic findings in 66 patients with ischemic heart disease were analysed to identify the risk factors of complications in the digestive system and to determine the methods for their prevention after myocardial revascularization. It was found that complications in the gastrointestinal tract develop after extracorporeal circulation more often in patients with lesions of the visceral branches of the abdominal aorta than in those without them. With purposeful preventive therapy and observance of definite precautions before, during, and after the operation, the incidence of complications in abdominal organs and the organs of the retroperitoneal space reduced to one fourth while the nature of these complications was less aggressive. This was confirmed by no postoperative deaths in the group of patients who had undergone preventive treatment.

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109 patients who underwent operation for formation of an aortocoronary shunt (ACS) were divided into 3 groups according to the method of introducing a cardioplegic solution and reperfusion. Thirty-five patients (group 1) underwent antegrade cardioplegia and direct reperfusion. Thirty-seven (group 2) were subjected to mixed antegrade-retrograde cardioplegia. Group 3 consisted of 37 patients with myocardial protection accomplished by the same method as in group 2, but retrograde perfusion was with warmed oxygenated blood through the right atrium was conducted before removing the clamp from the aorta. The effect of various types of pharmacocryocardioplegia on the appearance of new disorders of rhythm and conductivity in the early postoperative period after ACS formation was analysed. The frequency of sinus tachycardia was less in group 3 (24%) than in groups 1 and 2 (51 and 51%, respectively, p less than 0.05). We obtained no statistically significant differences in the frequency of other types of arrhythmias in these 3 groups. However, the number of transient bundle-branch blocks and disorders of intraventricular conductivity (8.1 and 10.8%, respectively) in group 3 was also less than that in groups 1 and 2 (p less than 0.05) and their regression was faster. We believe that combined anterograde-retrograde cardioplegia applied together with retrograde reperfusion with warmed oxygenated blood is most effective not only in protection of the conduction system of the heart but also in protection of the right- and left-ventricular myocardium.

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Since January 1988 till June 1990 145 patients with combined coronary and vascular pathology have been operated on. Concomitant damage of aortic arch branches was observed in 54 patients (37.2%), and aortocoronary bypass surgery was performed in 40 patients without correction of the carotid vascular bed pathology. These patients comprised the basic group, which was divided into two subgroups depending on the clinical pattern of the disease: subgroup I--18 asymptomatic patients (45.0%), subgroup II--22 patients (55.0%) with clinical signs of the disease. The basic group comprised 257 patients with CHD alone and no damages of the aortic arch branches. In the postoperative period 10 out of 40 patients of the basic group developed neurological complications: brain hypoxia, delirious syndrome (3 patients); brain hypoxia, pre-comatose condition (3 patients); brain hypoxia, comatose condition (2 patients); transitory ischemic attack (2 patients). No significant differences in the development of complications have been observed in patients of both subgroups. In the control group neurological complications developed in 9 out of 257 patients (3.5%). The comparison of reasons responsible for the onset of complications in both groups has shown that acute heart failure was significantly predominant (10%) in the basic group, as compared to control group (1.9%). It has been concluded that after aortocoronary bypass surgery the risk of neurological complications was higher in patients with the accompanying damage of the aortic arch branches than in patients with CHD alone; the onset of acute heart failure in the early postoperative period increases the risk of neurological complications in such patients.

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The work deals with the results of one-stage reconstructive surgical interventions in 15 patients with affection of the coronary arteries, abdominal aorta, and lower limb arteries. All patients underwent operation for the creation of an aortocoronary shunt in combination with various types of vascular reconstructive operations, including the formation of an ascending aorta -bifemoral shunt in 3 patients. The total hospital mortality was 26.7%. The authors discuss the indications and the surgical tactics of one-stage reconstructive interventions in combined affection of the coronary and peripheral arteries.

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On the basis of experience in reconstructive operations on 250 patients with combined affection of the coronary arteries, abdominal aorta, and arteries of the lower limbs the authors discuss the diagnostic and tactical features of surgical management of these patients. The article dwells upon the necessary preoperative diagnostic algorithm as well as that in tactical variants of surgical treatment: (1) one-stage reconstructive operations on several vascular beds; (2) successive stage-by-stage treatment of patients with combined vascular pathology; (3) reconstructive vascular intervention on only one of the vascular beds. Correct practical solution of all these problems allowed the authors to reduce postoperative lethality to 5.4% among this grave contingent of patients with combined vascular pathology.

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A comprehensive clinicoangiographic and functional examination was made of 180 patients with combined coronary and vascular abnormalities. With this, a diagnostic algorithm was developed, which determined the authors' approach to evaluation of the severity of patients and the choice of surgical policy. A total of 150 patients were operated on, the total mortality being 7.3%. The examination of operative and hospital mortality rates in patients with combined abnormalities showed that pre-aortocoronary bypass surgery before a reconstructive vascular operation in patients with severe coronary diseases made it possible to avoid serious coronary events in the following postoperative period.

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The authors in 145 patients with combined atherosclerotic lesion of the coronary arteries, abdominal aorta and vessels of the lower extremities performed the one-stage, staged operations, aortocoronary shunting alone, the vascular operations alone. The total lethality was 7.6%, the postoperative--6.3%.

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The authors performed 153 reconstructive vascular operations in patients with associated atherosclerotic lesion of the coronary arteries, abdominal aorta and arteries of the lower extremities. According to the findings of ventriculography and coronarograms, in 13 patients, the inoperable form of the ischemic heart disease was revealed. In all these patients, the vascular operations were performed. The indications for the different reconstructive vascular operations in inoperable coronary pathology have been developed.

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After examination of 255 patients with ischemic heart disease (IHD) and concomitant arterial hypertension (AH) two groups were distinguished according the level of arterial pressure. Group 1 was formed of 89 patients (arterial pressure below 180/80 mm Hg), group 2--of 166 patients (arterial pressure above 180/100 mm Hg). Survival was determined according to certain morphofunctional indices (total affection of coronary arteries, left ventricular output fraction, left ventricular end diastolic pressure, tolerance to physical effort) in nonoperated on and operated on patients suffering from IHD and concomitant AH. It was found that the operation affects positively the "quality" of life more than the survival.

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General theoretical aspects (classification of circulatory disorders and heart failure) and results of research into specific subdivisions of cardiovascular and respiratory system pathology in cardiac surgical patients are discussed. The material is aggregated by the applied clinico-mathematical approach that has been developed and introduced into clinical practice in the recent 15 years at the Bakulev Institute of Cardiovascular Surgery. The extension of the clinico-mathematical approach onto the intraoperative control and analysis of the patients' status, assessment of the anaesthetic administration and cardioplegic protection is first overviewed.

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The literature and original research data on the incidence of combined lesions of coronary arteries, abdominal aorta, and lower-limb vessels are presented. Operative intervention was undertaken in 112 of 170 examined patients with combined coronary and vascular abnormalities. Fifteen patients underwent one-stage reconstruction of the coronary artery and aortofemoral segment; in 57 patients aortocoronary bypass was performed as the first stage; in 40 patients only vascular reconstruction was performed. Operative risks in these patients are discussed, as well as the diagnostic problems, surgical tactics, and the sequence of operation stages in combined coronary and vascular abnormalities.

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