Does intensive perioperative dialysis improve the results of coronary artery bypass grafting in haemodialysed patients?
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BACKGROUND: Between January 1996 and April 1998, 17 chronic haemodialysed patients underwent coronary artery bypass grafting (CABG). Two of them simultaneously had valve replacement. METHODS: Except for two cases in which CABG was performed in an emergency, 15 patients (CRF group) received 3 consecutive days of haemodialysis in the preoperative period, intraoperative haemodialysis connected to cardiac pulmonary bypass (CPB) and continuous hemodiafiltration in the early postoperative period. The perioperative clinical parameters of the CRF group were compared with those of 17 age-matched patients with normal renal function undergoing CABG as the control (NRF group). RESULTS: When the perioperative variables were compared, no significant differences were seen in total operation time and CPB time, but we noted significant increases in the mean volume of transfused blood in the 6 perioperative days, postoperative intubation time, postoperative fasting time, and time spent in the intensive care unit. Levels of central venous pressure, systolic blood pressure, respiratory index (PaO2/FiO2) and daily fluid balance of the CRF group were the same as the control group in the early postoperative period. In addition, the levels of serum creatinine, urea nitrogen, potassium and hematocrit of CRF group remained almost constant in the early postoperative period. After all, the hospital morbidity of the CRF group was not more serious than that of the NRF group, and hospital mortality of the CRF and NRF groups was 0%. CONCLUSIONS: Our intensive perioperative dialysis programme could successfully manage the perioperative clinical course of haemodialysed patients undergoing CABG. (+info)
Strategy for balancing anticoagulation and hemostasis in aortocoronary bypass surgery: blood conservation and graft patency.
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The minimal effective dose of aprotinin on hemostasis under normothermic perfusion, the influence of anticoagulant therapy on graft patency, and the thromboembolic and hemorrhagic events were investigated after aortocoronary bypass graft operation (CABG). One hundred CABG patients under normothermic perfusion were randomly divided into the following groups: (1) coumadin plus acetylsalicylic acid (ASA) (n=32); no aprotinin used during cardiopulmonary bypass (CPB); (2) minimal-dose, 10(6) KIU during CPB, aprotinin used, followed by ASA and coumadin (n=36); and (3) very low-dose, total of 2x10(6) KIU before CPB and during CPB; aprotinin used; anticoagulation therapy with heparin early after surgery and followed by replacement with ASA and coumadin (n=32). The patency of arterial grafts was 100% in all groups. The patency of vein grafts was 95-98% and there was no difference among the groups. The blood loss was significantly reduced in both aprotinin groups (groups 2 and 3) compared to the coumadin plus ASA group, although no difference existed between the 2 aprotinin groups. Postoperative thrombotic and hemorrhagic events were not observed in any group. From this study, it was concluded that 10(6) KIU aprotinin in pump-prime-only followed by oral ASA and coumadin was the recommendation from the benefit/cost consideration. (+info)
Quality of life after coronary angioplasty or bypass surgery. 1-year follow-up in the Coronary Angioplasty versus Bypass Revascularization investigation (CABRI) trial.
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BACKGROUND: Coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) have both been shown to be safe and effective in the treatment of coronary artery disease. Nine randomized studies comparing CABG and PTCA have delivered consistent results, with no significant differences in mortality between the methods, either in single or in multivessel coronary artery disease. An important outcome measurement after intervention is the patient's subjective appraisal of the intervention. Results from the CABRI substudy on quality of life at 1 year follow-up are presented in this report. METHODS: CABRI is a multicentre, randomized, open comparison of patients assigned to either PTCA or CABG. Patients were recruited from 26 high volume European hospitals over a 53 month period starting in July 1988. A quality of life substudy was also set up, but participation was optional. Seven out of 26 centres took part in the study. One hundred and fifty-four (14.6%) out of the 1054 main study patients participated. Perceived health status was assessed at baseline and 1 year after revascularization by means of The Nottingham Health Profile and a set of 12 other questions. RESULTS: A significant improvement in quality of life in terms of the total score and in the Nottingham Health Profile for both groups, as compared with baseline, was found. A trend towards better outcome concerning energy was found favouring CABG. This trend might be due to the fact that the CABRI protocol permitted incomplete revascularization in the PTCA arm and did not exclude patients with totally occluded vessels. When adjusted for baseline differences, no difference in health-related quality of life at follow-up was found between the sexes, or between the PTCA and the CABG groups. A significant correlation was found between improvement in quality of life and severity of angina when adjusted for baseline values. CONCLUSIONS: This study has shown that there is no general difference in health-related quality of life 1 year after bypass surgery or angioplasty; however, data presented are suggestive of a more favourable outcome in degree of perceived energy in the bypass group. (+info)
Sustained suppression of ischemic complications of coronary intervention by platelet GP IIb/IIIa blockade with abciximab: one-year outcome in the EPILOG trial. Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade.
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BACKGROUND: Blockade of the platelet glycoprotein IIb/IIIa receptor with the monoclonal antibody fragment abciximab was shown in a placebo-controlled randomized trial to reduce the incidence of acute ischemic complications within 30 days among a broad spectrum of patients undergoing percutaneous coronary revascularization. The durability of clinical benefit in this setting has not been established. METHODS AND RESULTS: A total of 2792 patients enrolled in the Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade (EPILOG) trial were followed with maintenance of double-blinding for 1 year. Patients had been assigned at the time of their index coronary interventional procedure to receive placebo with standard-dose, weight-adjusted heparin (100 U/kg initial bolus), abciximab with standard-dose, weight-adjusted heparin, or abciximab with low-dose, weight-adjusted heparin (70 U/kg initial bolus). The primary outcome was the composite of death, myocardial infarction, or urgent repeat revascularization by 30 days; this composite end point and its individual components were also assessed at 6 months and 1 year. Rates of any repeat revascularization (urgent or elective), target vessel revascularization, and a composite of death, myocardial infarction, or any repeat revascularization were also reported. Follow-up at 1 year was 99% complete for survival status and 97% complete for other end points. By 1 year, the incidence of the primary composite end point was 16.1% in the placebo group, 9.6% in the abciximab with low-dose heparin group (P<0.001), and 9.5% in the abciximab with standard-dose heparin group (P<0.001). Each of the components of this composite end point was reduced to a similar extent. Nonurgent or target vessel repeat revascularization rates were not significantly decreased by abciximab therapy. Mortality rates over 1 year increased with increasing levels of periprocedural creatine kinase MB fraction elevation. CONCLUSIONS: Acute reductions in ischemic events after percutaneous coronary intervention by abciximab are sustained over follow-up to at least 1 year. Early periprocedural myocardial infarctions suppressed by this therapy are associated with long-term mortality rates. (+info)
Patient-related outcomes five years after coronary artery bypass graft surgery.
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For five years, we prospectively studied 353 consecutive patients undergoing first-time coronary artery bypass graft surgery (CABG) for stable angina in the North of England. Angina was present before surgery in nearly all patients, in 20% 3 months after surgery, and in 48% after 60 months. The Nottingham Health Profile, showed a significant improvement in perceived health status (PHS) 12 and 60 months after surgery compared with preoperation. However, PHS at 60 months was worse than at 12 months in the dimensions 'pain' and 'physical mobility' in part 1, and in 'looking after the home' and 'taking holidays' in part 2. Employment rates were 36%, 34% and 21%, before, and 12 and 60 months after surgery, respectively. Working at 12 and 60 months was associated with age below retirement age, work preoperation and absence of angina, and at 12 months also with male gender and waiting time < 6 months. This study describes everyday clinical practice. The significant improvement in angina symptoms and PHS after CABG persists for at least 5 years. However, only one third of patients in this geographical area return to work, and this is not solely dependent on clinical symptoms. (+info)
Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group.
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OBJECTIVE: To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES: Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS: Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS: Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated. (+info)
High apolipoprotein AI concentrations are associated with lower mortality and myocardial infarction five years after coronary artery bypass graft surgery.
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OBJECTIVE: To examine mortality and myocardial infarction five years after coronary artery bypass graft (CABG) surgery and the association with different lipid fractions and haemostatic, glycaemic, and demographic risk factors. SETTING: A regional cardiothoracic centre, Freeman Hospital, and the University Clinical Investigation Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK. DESIGN: 353 consecutive patients (297 male, mean age 57.2 years) undergoing first time CABG for stable angina were recruited to a prospective cohort study and studied to five years. MAIN OUTCOME MEASURES: All cause mortality, late cardiac mortality (beyond 30 days) alone and in combination with non-fatal myocardial infarction. Risk factor assessments before operation and 3, 6, 12, 24, and 60 months after surgery. For each laboratory variable a weighted mean for the period of exposure was calculated from the concentration at each time interval and the time between measurements. The distribution was divided into tertiles. RESULTS: 41 patients died (16 late cardiac deaths) and eight had a myocardial infarct. An adverse outcome occurred more frequently in the lower tertile of weighted apolipoprotein AI compared with the upper tertile. An adverse outcome was also more common in patients in the upper tertile of weighted total white blood cell count and less consistently so in patients in the upper tertile of the haemostatic covariates, factor VIIc and factor VIIIc. There was no association with other lipid fractions except for total mortality and apolipoprotein B (owing to low levels in five patients with carcinoma). CONCLUSIONS: Low apolipoprotein AI concentrations, but no other markers of an adverse lipid profile, were associated with mortality and myocardial infarction five years after CABG. Apolipoprotein AI is associated with paraoxonase, an enzyme located on high density lipoprotein, which may limit the oxidation of low density lipoprotein. An association between outcome and other covariates such as white cell count provides a credible pointer to inflammation mediating a component of cardiovascular risk. (+info)
Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass.
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OBJECTIVE: To compare cardiac troponin T release and lactate metabolism in coronary sinus and arterial blood during uncomplicated coronary grafting on the beating heart with conventional coronary grafting using cardiopulmonary bypass. DESIGN: A prospective observational study with simultaneous sampling of coronary sinus and arterial blood: before and 1, 4, 10, and 20 minutes after reperfusion for analysis of cardiac troponin T and lactate. Cardiac troponin T was also analysed in venous samples taken 3, 6, 24, 48, and 72 hours after surgery. SETTING: Cardiac surgical unit in a tertiary referral centre. PATIENTS: 18 patients undergoing coronary grafting on the beating heart (10 single vessel and eight two-vessel grafting) and eight undergoing two-vessel grafting with cardiopulmonary bypass. RESULTS: Cardiac troponin T was detected in coronary sinus blood in all patients by 20 minutes after beating heart coronary artery surgery before arterial concentrations were consistently increased. Peak arterial and coronary sinus cardiac troponin T values on the beating heart during single (0.03 (0 to 0. 05) and 0.09 (0.07 to 0.16 microg/l, respectively) and two-vessel grafting (0.1 (0.07 to 0.11) and 0.19 (0.14 to 0.25) microg/l) were lower than the values obtained during cardiopulmonary bypass (0.64 (0.52 to 0.72) and 1.4 (0.9 to 2.0) microg/l) (p < 0.05). The area under the curve of venous cardiac troponin T over 72 hours for two-vessel grafting on the beating heart was less than with cardiopulmonary bypass (13 (10 to 16) v 68 (26 to 102) microg.h/l) (p < 0.001). Lactate extraction began within one minute of snare release during beating heart coronary surgery while lactate was still being produced 20 minutes after cross clamp release following cardiopulmonary bypass. CONCLUSIONS: Lower intraoperative and serial venous cardiac troponin T concentrations suggest a lesser degree of myocyte injury during beating heart coronary artery surgery than during cardiopulmonary bypass. Oxidative metabolism also recovers more rapidly with beating heart coronary artery surgery than with conventional coronary grafting. Coronary sinus cardiac troponin T concentrations increased earlier and were greater than arterial concentrations during beating heart surgery, suggesting that this may be a more sensitive method of intraoperative assessment of myocardial injury. (+info)