RESUMEN
BACKGROUND: The radial artery is being used with increasing frequency instead of the saphenous vein in coronary artery bypass grafts. We analyzed the in-hospital and midterm results in patients undergoing coronary artery bypass surgery in whom a combination of arterial grafts was used, including radial artery and one or both internal mammary arteries. METHODS: Between 1995 and 1998, 1,023 patients underwent coronary artery bypass surgery using arterial conduits. The left internal mammary artery and the right internal mammary artery were employed in combination with the radial artery. RESULTS: An average of 3.2 grafts per patient were done. The left internal mammary artery and radial artery were used in 100% of patients, the right internal mammary artery in 21.7%, and a venous graft in 31%. The operative mortality rate was 2.5%. On repeat angiography performed in 62 patients before their discharge, the arterial conduits were patent in 98.4%. Mean follow-up was 25.0 +/- 9.6 months (1 to 48 months). The probability of survival was 92.8%. CONCLUSIONS: Revascularization using mammary and radial artery grafts is safe. Complications are not higher than those observed with saphenous vein grafting. It was possible to use arterial conduits in all the patients, even in those with impaired left ventricular function.
Asunto(s)
Anastomosis Interna Mamario-Coronaria/métodos , Revascularización Miocárdica/métodos , Arteria Radial/trasplante , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Tasa de SupervivenciaRESUMEN
A 66-year-old man with a history of hypertension and ascending aortic replacement because of a type A dissection had 3 successive embolic events (left lower limb, brain, and spleen). Two consecutive transesophageal echocardiography studies showed mobile masses in the ascending aorta. The patient was reoperated without a certain etiologic diagnosis, and an unsuspected fungal endocarditis caused by an unusual germ (Trichoderma species) was found. Transesophageal echocardiography proved very useful in the management of this uncommon case of endocarditis.
Asunto(s)
Enfermedades de la Aorta/etiología , Ecocardiografía Transesofágica , Embolia/etiología , Endocarditis/complicaciones , Endocarditis/diagnóstico por imagen , Anciano , Endocarditis/microbiología , Humanos , Masculino , TrichodermaRESUMEN
BACKGROUND: Our objective was to determine whether complete myocardial revascularization "off pump" was feasible while maintaining the efficacy of conventional surgical techniques. METHODS: 264 patients were operated on between March 15, 1998, and August 26, 1999. A total of 218 (82.6%) were men and the average age was 61.4 years (range 28 to 87 years). Left main occlusions were present in 10.2% and 84% had multiple vessel disease. A total of 628 grafts were implanted, an average of 2.4 grafts per patient. Total arterial revascularization was achieved in 81.5% using both internal mammary arteries and the radial artery, one or more venous grafts in 18.1%, and venous alone in 0.3%. RESULTS: Surgical mortality was 2.2% and perioperative myocardial infarction was 3%. There were no neurologic events in this group of patients. In the first 73 patients coronary angiography control was performed before discharge and all grafts were patent. Angioplasty was carried out in 2 patients (0.76%) and conversion of procedure in 4 (1.5%). Follow-up time was 4 to 14 months. CONCLUSIONS: This procedure enabled revascularization of all areas of the heart, usually with total arterial revascularization, and excellent patency rates. The morbidity and mortality observed was similar to conventional surgery. The incidence of secondary complications (bleeding, need for transfusion, prolonged mechanical ventilation, or neurologic events) was lower.
Asunto(s)
Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Revascularización Miocárdica/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/cirugía , Revascularización Miocárdica/mortalidad , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The main objective of the present study was to analyze the in-hospital and mid term results obtained in 1,023 consecutive patients undergoing coronary artery bypass surgery (CABG) in whom a combination of arterial grafts was used: radial arteries (RA) and one or both internal mammary arteries (IMA). METHODS: From May 1995 to May 1998, 1,023 consecutive patients underwent CABG alone, using arterial conduits (AC) (one or two IMA and RA) for myocardial revascularization. The left internal mammary artery (LIMA) was employed as an "in situ" graft, and the right internal mammary artery (RIMA) as a free graft or "in situ" both in combination with the RA. The latter was connected to the LIMA through a T or Y anastomosis, or emerged directly from the ascending portion of the aorta. RESULTS: An average of 3.2 bypasses per patient were performed. The LIMA was used in 100% of the patients. The RIMA was used in 21.7% and the RA in 100% of the cases. Operative mortality was 2.5% (26 patients) and 32 (3.1%) suffered perioperative acute myocardial infarction. The first 62 patients were angiographically re-studied before discharge, and a 98.4% patency of the AC used was found. Mean follow up time was 25.0 +/- 9.6 months (range, 1 to 48 months). CONCLUSIONS: a) myocardial revascularization procedures using a combination of mammary and RA grafts are safe; b) in-hospital and mid term morbidity and mortality are not higher than those observed with saphenous vein grafts; c) it is possible to achieve complete myocardial revascularization with only AC, even in patients with impaired left ventricular function, and d) AC can be used in elderly patients.
Asunto(s)
Anastomosis Interna Mamario-Coronaria/métodos , Adulto , Anciano , Anciano de 80 o más Años , Argentina/epidemiología , Angiografía Coronaria/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Anastomosis Interna Mamario-Coronaria/mortalidad , Anastomosis Interna Mamario-Coronaria/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Arteria Radial/trasplante , Factores de TiempoRESUMEN
OBJECTIVE: We prospectively analyzed the short- and long-term results of manual debridement of the aortic valve in elderly patients with severe degenerative aortic stenosis. METHODS: Between September 1988 and January 1997, 103 patients aged 73.7 +/- 6 years with degenerative aortic stenosis underwent the manual debridement technique. All had symptoms (angina or dyspnea, or both). Peak systolic gradient was 89 +/- 28 mm Hg. Forty-one patients (39.8%) had associated coronary artery disease necessitating revascularization. RESULTS: Follow-up time was 42 +/- 21 months (range 3-98 months). The Kaplan-Meier estimated survival at 98 months was 50% (95% CI: 30%-70%). In-hospital mortality was 5.8% (6 patients), and late mortality was 21% (21 patients). No predictors of in-hospital mortality or of late mortality were detected. Nonfatal postoperative complications appeared in 25 patients (24%). At 8 years, freedom from endocarditis was 98% (95% CI: 95%-100%) and freedom from thromboembolic events was 99% (95% CI: 96%-100%). No patient required long-term anticoagulation as a result of the procedure. Fourteen patients (14%) required reoperation for aortic insufficiency (n = 5), restenosis (n = 8), and mitral regurgitation (n = 1). The probability of reoperation at 98 months was 23% (95% CI: 12%-35%). CONCLUSION: Manual aortic valve debridement has low rates of in-hospital mortality, perioperative complications, and thromboembolic and infectious events and it offers freedom from anticoagulation. However, the incidence of restenosis and reoperation is high in the long term. It may therefore be regarded as an alternative in aged patients with favorable valve anatomy (no distortion and calcium deposits only on the aortic surface of the cusps), especially in those with a small aortic anulus, associated coronary artery disease, and/or contraindication for anticoagulation.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Desbridamiento , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/mortalidad , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Masculino , Complicaciones Posoperatorias , Estudios Prospectivos , Reoperación , Tasa de SupervivenciaRESUMEN
A rare development of acute inferior myocardial infarction is reported in a 23-year-old man with no previous history of cardiovascular disease. In an echocardiographic study a left intraventricular tumour was diagnosed. Cineangiographic study showed normal coronary arteries. The tumour, a myxoma, originating in the ventricular septum, was resected through the left atrium after the anterior leaflet of the mitral valve was detached. Postoperative course was uneventful and the patient remained healthy 48 months after surgery.
Asunto(s)
Neoplasias Cardíacas/complicaciones , Infarto del Miocardio/etiología , Mixoma/complicaciones , Adulto , Procedimientos Quirúrgicos Cardíacos , Cineangiografía , Angiografía Coronaria , Ecocardiografía , Estudios de Seguimiento , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/cirugía , Humanos , Masculino , Infarto del Miocardio/diagnóstico , Mixoma/diagnóstico , Mixoma/cirugíaRESUMEN
BACKGROUND: In recent years, minimally invasive direct coronary artery bypass grafting has emerged as a valid tool for revascularization in a select group of patients with severe lesions of the left anterior descending coronary artery. Here we report the clinical results using two devices designed by us to facilitate the harvesting of the left internal mammary artery up to its origin and to occlude and stabilize the left anterior descending coronary artery while placing the anastomosis. METHODS: From January 1996 to January 1998, 122 patients underwent minimally invasive direct coronary artery bypass grafting in the Department of Cardiac Surgery, Favaloro Foundation. One hundred twelve patients received a single left internal mammary artery-left anterior descending coronary artery bypass graft, and in 10 patients, an additional bypass graft was performed. RESULTS: Most patients were discharged on day 2 or 3 after the procedure. Three patients (2.5%) had a perioperative myocardial infarction. The overall hospital mortality rate was 3.3% (4 patients). CONCLUSIONS: The combination of team experience, more careful dissection of the left internal mammary artery up to its origin, and use of the stabilizer-occluder and interrupted suture technique for the anastomosis has markedly improved our results.
Asunto(s)
Puente de Arteria Coronaria/métodos , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/métodos , Puente de Arteria Coronaria/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Análisis de Supervivencia , Técnicas de Sutura , Toracotomía/métodosRESUMEN
BACKGROUND: We analyzed in-hospital results of 87 patients undergoing minimally invasive valvular operations (right parasternal incision through third and fourth cartilages). METHODS: Age was 21 to 84 years (mean, 56.2 +/- 16); 45 patients (51.7%) were female. Five (5.7%) had a previous valvular operation and 8 (9.2%) had severe left ventricular dysfunction. Valve diseases were as follows: aortic in 35 patients (40.2%), mitral in 44 (50.5%), double in 5 (5.7%), tricuspid regurgitation in 2 (2.2%), and mitral periprosthetic leak in 1 (1.1%). RESULTS: Nineteen mitral repairs (21.9%), 22 replacements (25.3%), 1 leak closure (1.1%), 1 tricuspid repair (1.1%), and 1 replacement (1.1%) were performed. Thirty-one patients (35.7%) underwent aortic replacement, 2 (2.3%) aortic decalcification, 1 (1.1%) subaortic membrane resection, 4 (4.6%) a double-valve procedure, and 5 (5.7%) a single-valve operation combined with myocardial revascularization. In-hospital mortality was 5.7% (5 patients). Univariate analysis was significant for previous operation, New York Heart Association class IV and severe ventricular dysfunction. Multivariate analysis was significant for previous operation and severe ventricular dysfunction. Atrial fibrillation (12.6%) was the most frequent complication. Postoperative stay was 6.5 +/- 6 days. CONCLUSIONS: The minimally invasive approach is a useful technique in valvular surgery. Patients with a previous valvular operation, severe ventricular dysfunction, and New York Heart Association class IV dyspnea have higher in-hospital mortality.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/métodos , Femenino , Enfermedades de las Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Resultado del TratamientoRESUMEN
OBJECTIVE: We prospectively tested the feasibility of achieving total arterial revascularization with the use of the radial artery to revascularize the circumflex, diagonal, and right coronary arteries combined with a left internal thoracic artery graft to the left anterior descending artery and, in some cases, a right internal thoracic artery graft to the right coronary artery. METHODS: In 164 patients, the radial artery was used as a free Y or T graft from the left internal thoracic artery. Of 568 grafts (3.5 +/- 1 [standard deviation] per patient), 296 (1.8 +/- 0.8 per patient) were constructed with the radial artery as single grafts or as double, triple, or quadruple sequential anastomoses to the circumflex, diagonal, and posterior descending arteries. Diltiazem was administered to prevent spasm. Forty-six patients underwent coronary angiography before discharge from the hospital. Follow-up time was 1 to 19 (9.5 +/- 6.1) months. RESULTS: Total arterial revascularization was achieved in 137 patients (83.5%). Three (1.8%) died postoperatively of sepsis, ventricular fibrillation, and heart failure, respectively. Three (1.8%) had postoperative myocardial infarction. No hand ischemia occurred. Angiography showed patency of all arterial conduits. Radial artery spasm appeared in 3 (6.5%) of 46 angiograms. Two patients (1.2%) died during the follow-up period of pneumonia and gastrointestinal tract bleeding, respectively. No other events or reoperations occurred, and 95.1% of the patients are free of symptoms. CONCLUSIONS: The radial artery, as a free Y or T graft from the left internal thoracic artery to the circumflex, diagonal, and right coronary arteries, permits total arterial revascularization with excellent patency rates, minimal morbidity and mortality, and no need for reoperation. Longer follow-up times are necessary to draw definitive conclusions.
Asunto(s)
Enfermedad Coronaria/cirugía , Anastomosis Interna Mamario-Coronaria/métodos , Arteria Radial/trasplante , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico por imagen , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Factores de Tiempo , Grado de Desobstrucción VascularRESUMEN
We present an analysis of 59 patients operated on between 1983 and 1987 for acute type A dissecting aneurysm with aortic valve insufficiency. The ascending aorta was replaced with a Dacron tube, the layers of the dissection were unified with gelatin-resorcine-formaldehyde glue, and the natural aortic valve was preserved. Follow-up every 6 months was subject to actuarial analysis. The hospital mortality rate was 22%. The survivors were studied for 35.9 +/- 18.6 months (mean +/- standard deviation). Eight patients died (six of cardiovascular causes, one of cancer of the colon, and one of an unknown cause). Seventeen (36.9%) had aortic insufficiency, eight mild and nine moderate to severe. Four patients with severe insufficiency had reoperation with valve replacement. Excluding patients who have died or undergone reoperation, 29 of the remainder (90.6%) are free of symptoms. The follow-up survival rate is 61% +/- 6.93% (standard error) including hospital mortality. It is 55.4% +/- 7% (standard error) excluding reoperation and 44.2% +/- 7.1% (standard error) additionally excluding modest or severe aortic insufficiency. The use of gelatin-resorcine-formal glue allowed preservation of the native aortic valve, obviating the need for anticoagulants, and no embolic or hemorrhagic episodes were registered.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/complicaciones , Formaldehído , Gelatina , Resorcinoles , Adolescente , Adulto , Anciano , Disección Aórtica/complicaciones , Disección Aórtica/mortalidad , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/mortalidad , Prótesis Vascular , Combinación de Medicamentos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Métodos , Persona de Mediana Edad , Reoperación , Adhesivos TisularesRESUMEN
The combination of deep hypothermia and circulatory arrest has been used in a variety of cardiovascular surgical techniques and is presented in this article as an elective method in the treatment of type B dissecting aneurysms that may or may not involve the distal aortic arch. Out of 190 patients operated on with acute aortic dissection, 10 patients with type B underwent surgical procedures, between January 1985 and December 1987, four with acute dissection (less than 14 days evolution), and six with chronic dissection (more than 14 days evolution). The approach was by left posterolateral thoracotomy with cardiopulmonary bypass using femoro-femoral cannulation, deep hypothermia, and circulatory arrest. The duration of circulatory arrest was between 27 and 58 minutes, mean 37 minutes. Extracorporeal circulation (ECC) lasted between 68 and 142 minutes, with a mean perfusion time of 83.7 minutes, and temperature fell to 14 degrees C and 16 degrees C. Intrahospital mortality was 20% (two patients). No long-term mortality has been recorded. Eighty percent of the patients (eight patients) are alive and showed good evolution between 10 and 44 months following surgery, with a long-term mean survival of 24 months and 23 days. The only neurological complication was a single case of right unilateral blindness followed by complete visual recuperation. Myocardial and spinal cord protection are excellent, without any incidence of postoperative infarct or paraplegia. Postsurgical blood loss ranged from 200 to 650 mL with a mean of 385 mL. Acute renal insufficiency was not detected. We believe that the combined techniques of deep hypothermia and circulatory arrest used electively, and not just out of occasional necessity, is a viable choice that allows easier surgical manipulation of type B dissection aneurysms and complete resolution of those involving retrograde dissection to the aortic arch. In addition. this combined technique does not increase postoperative mortality in this critically dangerous disease.