Technique: Continuous Retrograde Cardioplegia Followed by Warm Blood Antegrade Infusion

The optimum myocardial preservation technique during cardiopulmonary bypass procedures remains widely debated. It is believed that the efficacy of the myocardial preservation technique is largely responsible for post-operative myocardial function and recovery. At the Miami Heart Institute, a recently developed technique has been under investigation. It is the purpose of this report to reveal the latest research findings on what we believe to be a superior form of myocardial preservation. Fifty patients who underwent cardiac operations were randomly selected for this study. In each patient, the technique of retrograde cardioplegia was employed. The cardioplegia was administered continuously in retrograde fashion in order to maintain a myocardial temperature range of 6° - 12°C throughout the ischemic period. Shortly before aortic cross clamp removal, warm pump blood was administered antegrade fashion through the aortic root. Aortic root pressure was strictly maintained between 75 - 85 mmHg to insure adequate infusion into the coronary arteries. The result of the retrograde technique has been strict mainteance of myocardial hypothermia throughout the ischemic period. The antegrade warm blood infusion permits adequate myocardial reperfusion and rewarming. The result of this warm blood infusion has been a spontmteous reinstitution of of the patient's cardiac rhythm without a fibrillation period. Of patients undergoing this technique, 94% experienced no cardiac fibrillation at any time during the operation. While marked improvement in post-operative myocardial function has been observed and is currently under data accumulation, it is our conclusion that this technique is a significant advancement in the field of myocardial preservation (J. Extra-Corpor Technol, 21(2): 56-60, 1989, 15 Ref)

Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians

Despite well-established benefits of arterial (ART) grafting, surgeons have been reluctant to use this conduit in octogenarians. This study explores the influence of arterial revascularization on operative and long-term outcomes of coronary artery bypass grafting surgery. A retrospective analysis was conducted of 987 consecutive patients 80 years of age or older who underwent isolated coronary artery bypass grafting between January 1989 and November 2000. Patients with saphenous vein graft only (SVG; n = 574) were compared with those receiving arterial and saphenous vein grafts (ART+SVG; n = 413). Mean follow-up for SVG patients was 3.8 years (range, 4 months to 12.6 years) and 98.6% complete, and mean follow-up was 3.1 years for ART+SVG patients (range, 2 months to 11.2 years) and 97.3% complete. Patients with SVG had a significantly higher ( p = 0.009) operative mortality (11.1% versus 6.3%) and significantly longer postoperative length of stay (12.9 versus 10.7 days; p = 0.002) than ART+SVG recipients. More ART+SVG than SVG patients were free of all postoperative complications (290 of 413; 70.2% versus 372 of 574; 64.8%; p = 0.086). Multivariable analysis identified SVG as an independent predictor of operative mortality ( p = 0.014) and late mortality ( p = 0.040). When patients were matched by equivalent propensity scores to receive SVG only, operative mortality was higher for SVG patients in four of the five quintiles. At 10 years, 97.0% ± 1.2% of SVG and 92.9% ± 3.7% of ART+SVG current survivors were free of all late major adverse cardiac events ( p = 0.565), and 95.5% of SVG patients and 97.5% of ART+SVG patients were in Canadian class 1 or 2 ( p = 0.162). On the SF-36 quality-of-life assessment, ART+SVG patients scored significantly higher than both SVG patients and age-adjusted normal subjects. Physical health summary component scores were 36.8 ± 11.0 for SVG and 41.0 ± 10.3 for ART+SVG ( p = 0.001). Mental health summary scores were comparable for the two groups. Arterial grafting confers an operative survival benefit, and an enhanced long-term quality of life in elderly patients

Bilateral internal mammary artery grafting in women: A 21-year experience

Coronary artery bypass grafting traditionally has carried a higher mortality rate in women than in men. It remains the leading cause of death in women despite major advances in diagnosis and treatment over the past 2 decades. A retrospective analysis was conducted to identify risk factors that adversely influence hospital mortality, morbidity, and long-term clinical results in women undergoing bilateral internal mammary artery grafting. From January 1972 through October 1994, 327 consecutive women received bilateral internal mammary artery grafts and supplemental vein grafts. Patient age ranged from 32 to 84 years (mean, 65.7 years). There were 262 patients (80.1%) with three-vessel disease; 71 (21.7%) had substantial (>50%) stenosis of the left main coronary artery, 65 (19.9%) had a moderately reduced (0.30 to 0.50) ejection fraction, and 11 (3.4%) had a severely reduced (<0.30) ejection fraction. Preoperatively, 316 patients (96.6%) were in New York Heart Association class III or IV. There were 1,016 coronary artery grafts (mean, 3.1 per patient). The overall hospital mortality rate was 3.4% (11 of 327). Postoperative complications included myocardial infarction in 18 patients (5.5%), stroke in 5 (1.5%), pulmonary insufficiency in 11 (3.4%), reoperation for bleeding in 7 (2.1%), and sternal infection in 8 (2.4%). Independent predictors of operative death were postoperative cardiac arrest (p < 0.001), use of intraaortic balloon pump (p < 0.001), and reoperation for bleeding (p < 0.050). Follow-up was completed on 316 hospital survivors (100%) and ranged from 6 months to 21 years (mean, 5.1 years). Actuarial survival (mean ± standard error of the mean) was 90.5% ± 1.9% at 5 years and 65.6% ± 6.1% at 10 years. At follow-up, 252 patients (94.0%) were asymptomatic in New York Heart Association class I, and 12 (4.5%) were in class II. This longitudinal study demonstrates that bilateral internal mammary artery grafting, though technically demanding, can be achieved in women with low hospital mortality and morbidity rates. Patients experienced reduced late cardiac events, excellent functional improvement, and enhanced long-term survival