Mechanisms, Consequences, and Prevention of Coronary Graft Failure

Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure.

Prosthesis size and long-term survival after aortic valve replacement

OBJECTIVE

This study was undertaken to quantify the relationship between prosthesis size adjusted for patient size (prosthesis-patient size) and long-term survival after aortic valve replacement.

METHODS

Data from nine representative sources on 13,258 aortic valve replacements provided 69,780 patient-years of follow-up (mean 5.3 +/- 4.7 years), with reliable survival estimates to 15 years. Prostheses included 5757 stented porcine xenografts, 3198 stented bovine pericardial xenografts, 3583 mechanical valves, and 720 allografts. Manufacturers' labeled prosthesis size was 19 mm or smaller in 1109 patients. Expressions of prosthesis-patient size assessed were indexed internal prosthesis orifice area (in centimeters squared per square meter of body surface area) and standardized internal prosthesis orifice size (Z, the number of SDs from mean normal native aortic valve size). Multivariable hazard domain analysis with balancing score and risk factor adjustment quantified the association of prosthesis-patient size with survival.

RESULTS

Prosthesis-patient size down to at least 1.1 cm(2)/m(2) or -3 Z did not adversely affect intermediate- or long-term survival (P >.2). However, 30-day mortality increased 1% to 2% when indexed orifice area fell below 1.2 cm(2)/m(2) (P =.002) or standardized orifice size fell below -2.5 Z (P =.0003). The increased early risk affected fewer than 1% of patients receiving bioprostheses but about 25% of those receiving mechanical devices.

CONCLUSIONS

Aortic prosthesis-patient size down to 1.1 cm(2)/m(2) or -3 Z did not reduce intermediate- or long-term survival after aortic valve replacement. However, patient-prosthesis size under 1.2 cm(2)/m(2) or -2.5 Z was associated with a 1% to 2% increase in 30-day mortality. Prosthesis-patient sizes this small or smaller were rarely implanted in patients receiving bioprostheses.

Radial artery has higher receptor-mediated contractility but similar endothelial function compared with mammary artery

BACKGROUND

The radial artery (RA) has been used as an alternative arterial graft for coronary artery bypass grafting, but this artery has been suggested to be spastic. Endothelin-1 (ET) and angiotensin II (AII) have been measured with increased plasma concentrations during cardiopulmonary bypass. However, whether RA is reactive to these two important receptor-mediated vasoconstrictors is unknown. Also unknown is the endothelial function of this arterial conduit. This study was designed to compare RA and the internal mammary artery regarding the contractile characteristics to ET-1 and AII and endothelial function.

METHODS

Ring segments of the RA and internal mammary artery taken from patients undergoing coronary artery bypass grafting were studied in organ chambers at a physiologic pressure. The contractility was determined from the contraction induced by ET-1 and AII as contraction force and the force normalized by circumference (g/mm). The endothelium-dependent relaxation was induced by the calcium ionophore A23187, a nonreceptor agonist, and substance P, a receptor agonist for endothelium-derived relaxing factors. Nitroglycerin was used to study the endothelium-independent relaxation.

RESULTS

Both ET-1 and AII induced a higher contraction force (9.0 +/- 0.9 g, n = 12, versus 4.5 +/- 0.4 g, n = 38, p < 0.0001 for ET and 6.5 +/- 1.9 g, n = 7, versus 1.7 +/- 0.3 g, n = 8, p = 0.015 for AII) and normalized force (0.95 +/- 0.1 g/mm versus 0.66 +/- 0.05 g/mm, p = 0.007 for ET-1 and 0.8 +/- 0.2 g/mm versus 0.2 +/- 0.05 g/mm, p < 0.01 for AII) in RA than in the internal mammary artery. There were no significant differences detected between these arteries with regard to either endothelium-dependent (to substance P and A23187) or endothelium-independent (to nitroglycerin) relaxation (p > 0.05).

CONCLUSIONS

We conclude that the human RA has a higher receptor-mediated contractility (to ET-1 and AII) but similar endothelial function compared to the internal mammary artery. The study reveals the nature of the more spastic characteristics of the RA, supports the necessity of a more active pharmacologic intervention to relieve spasm in the RA, and suggests that the similar endothelium-derived relaxing factor-mediated endothelial function of the RA compared with the internal mammary artery may be the basis for a satisfactory long-term patency.

Reactivity of the canine isolated internal mammary artery, saphenous vein, and coronary artery to constrictor and dilator substances: relevance to coronary bypass graft surgery

The internal mammary artery (IMA) and saphenous vein (SV) are used routinely in coronary artery (CA) bypass graft surgery. The IMA may develop spasm during surgery, and the SV often develops spasm during removal from the leg. We sought to determine the relative reactivity of the canine CA, IMA, and SV to potential vasoconstrictor substances and especially to determine which vasodilator agents were effective in these different blood vessels. All vessels were arranged as ring segments suspended at optimal stretch in organ baths. Glyceryl trinitrate (GTN) caused relaxation of the three vessels but was less sensitive, less potent (as determined by EC50 values), and had a reduced range of relaxation in the IMA. Papaverine was less sensitive in the IMA as compared with the CA and SV. Nifedipine, verapamil, and diltiazem were potent relaxing agents in all three vessels when precontracted by K+, but were less potent in vessels contracted by the thromboxane mimetic U46619 or phenylephrine, especially in the SV. These studies highlight the marked differences in the response of IMA and CA to constrictor and dilator agents and reinforce the notion that calcium antagonists of different chemical classes have widely differing activities in vascular tissue.

Comparison among arterial grafts and coronary artery. An attempt at functional classification

Various arterial conduits have been used for coronary artery bypass grafting. However, arterial grafts are not uniform either in anatomy or in function. Some conduits are more spastic than others and there may be possible differences in long-term patency rates. The diverse biologic characteristics promote a necessity of classification of arterial grafts, which may facilitate the understanding of surgeons of biologic characteristics of various arterial grafts and provide a scientific basis for searching for new grafts. Another important issue is the comparison of reactivity between arterial grafts and coronary arteries. In this study, we aim to compare the pharmacologic reactivity among the human arteries (grafts and coronary arteries) and to classify arterial grafts. Segments of three arterial grafts (gastroepiploic, internal mammary, and inferior epigastric) taken from patients undergoing coronary artery bypass grafting and coronary arteries taken from explanted hearts were studied in organ baths for the contraction to four vasoconstrictors (endothelin-1, thromboxane A2 mimetic U46619, full adrenoceptor agonist norepinephrine, and depolarizing agent potassium) under physiologic pressure. The diameter of the four arteries at a pressure of 100 mm Hg was similar (p > 0.05). However, the gastroepiploic artery contracted to higher forces (9.41 +/- 2.0 gm for endothelin, 11.79 +/- 1.85 gm for U46619, 13.54 +/- 2.7 gm for norepinephrine, and 11.11 +/- 1.97 gm for potassium) than did the coronary artery and internal mammary artery (p < 0.05) for all the tested vasoconstrictors and higher than the inferior epigastric artery for potassium and norepinephrine (p < 0.05). There was no significant difference among the other three arteries (internal mammary artery, inferior epigastric artery, and coronary artery) regarding the maximal contraction force to any vasoconstrictor. No difference was detected in regard to the sensitivity (effective concentration causing 50% of the maximal response) to the vasoconstrictors among the four arteries. This study reveals that among the arterial grafts and the coronary artery, the gastroepiploic artery has the highest contractility to various vasoconstrictors. On the basis of our findings and physiologic and embryologic knowledge we propose a classification for arterial grafts: type I (somatic arteries), type II (splanchnic arteries), and type III (limb arteries). Types II and III are prone to spasm because of higher contractility whereas type I arteries are usually less spastic. This classification may have important clinical implications for the understanding of arterial graft spasm or patency and may be useful in the search for new grafts.

Risk factors for development of acute renal failure (ARF) requiring dialysis in patients undergoing cardiac surgery

Acute renal failure (ARF) is one of the major complications after cardiopulmonary bypass for open heart operations. The present study was undertaken to identify the risk factors for the development of ARF following cardiopulmonary bypass (CPB). Four hundred and forty-seven consecutive patients who underwent open heart procedures from July 1994 to June 1995 were analyzed retrospectively. Their mean age was 55.6 +/- 14.2 (SD) years (range, 18 to 80). Dialysis was instituted whenever a patient exhibited inadequate urine output (<0.5 mL/kg/hr) for 2 to 3 hours despite correction of hemodynamic status and diuretic therapy, especially if fluid overload, hyperkalemia, or metabolic acidosis were also present. Twenty variables were analyzed by univariate analysis; these included nine preoperative variables--age, sex, hypertension, atherosclerosis, diabetes mellitus, left ventricular end-diastolic dimension (LVEDD) >5 cm, preoperative congestive heart failure, renal insufficiency (serum creatinine > or =130 micromol/L on two occasions), and sepsis--10 intraoperative variables--duration of CPB, redo procedures, emergency surgery, use of intraaortic balloon pump (IABP) in operating room, use of gentamicin, use of ceftriaxone, use of sulbactam/ampicillin, requirement of deep hypothermic circulatory arrest, duration of low mean perfusion pressure (mean pressure <50 mmHg for more than 30 minutes), operation on multiple valves--and one postoperative variable--significant hypotension (systolic blood pressure less than 90 mmHg for more than 1 hour). Significant variables or the variables having a trend (p<0.1) to be associated with ARF were included in stepwise multiple logistic regression analyses. Three regression analyses were performed separately. The incidence of ARF requiring dialysis in the study period was 15.0%. Significant risk factors for whole group of patients (regression I) were preoperative renal insufficiency (p<0.0001), postoperative hypotension (p<0.0001), cardiopulmonary bypass time more than 140 min (p<0.005), preoperative congestive heart failure (p<0.01), and history of diabetes mellitus (p<0.01). The risk factors in the valve group of patients (regression II) were preoperative renal insufficiency (p<0.0001) and postoperative hypotension (p<0.05). Risk factors in the CABG patients (regression III) were postoperative hypotension (p=0.0001), CPB time more than 140 min (p<0.05), preoperative renal insufficiency (p<0.05), and age (p<0.05). The authors conclude that preoperative renal insufficiency and postoperative hypotension are the most important independent risk factors for ARF in postcardiac surgical patients. In addition, CPB time greater than 140 minutes and old age are also independent risk factors for ARF in CABG patients. CPB time more than 140 minutes, history of diabetes mellitus, and preoperative congestive heart failure are independent risk factors for development of ARF in our total group of patients. These findings may have important clinical implications in the prevention of ARF in postcardiac surgical patients.

Arterial grafts for coronary artery bypass grafting: biological characteristics, functional classification, and clinical choice

Various arterial grafts have been used for coronary artery bypass grafting, but a unanimous opinion on how to best use these grafts has not been formed. Arterial grafts are not uniform in their biological characteristics. Differences between the perioperative behavior of the grafts and their long-term patency may be related to different characteristics. These characteristics should be taken into account in the use of arterial grafts, some of which are subject to more active pharmacologic intervention during and after operation to obtain satisfactory results. Clinical choice of grafts must be based on the general condition of the patient, the biological characteristics of the graft, the anatomy of the coronary artery, the match between the coronary artery and the graft, and technical considerations, including antispastic management.

Effects of biatrial pacing in prevention of postoperative atrial fibrillation after coronary artery bypass surgery

BACKGROUND

Atrial fibrillation (AF) is common after coronary artery bypass surgery (CABG) and results in prolonged hospitalization. The purpose of this study was to evaluate the efficacy of biatrial pacing in preventing post-CABG AF compared with single-site atrial pacing.

METHODS AND RESULTS

A total of 132 patients who had no history of AF and who underwent CABG were randomized to 1 of the following 4 groups: biatrial pacing (BiA), left atrial pacing (LA), right atrial pacing (RA), or no pacing (control) in postoperative period. Overdrive atrial pacing was performed for 5 days. The incidence of AF was significantly reduced in the BiA group (12.5%) compared with the other 3 groups (LA, 36.4%; RA, 33.3%; control, 41. 9%; P<0.05). The mean length of hospital stay was significantly reduced in the BiA group. At baseline, the mean P-wave duration (P(dur)) and dispersion (P(dis)) were not prolonged. BiA pacing resulted in the most significant percentage of reduction in P(dis) when compared with the LA or RA groups (BiA, 42+/-8%; LA, 13+/-6%; RA, 10+/-9%; P<0.05 for BiA versus LA or RA). No significant differences existed in mean P(dur) and P(dis) between patients who developed AF and those who remained in sinus rhythm at baseline. However, only those patients who remained in sinus rhythm had a significant reduction in mean P(dur) and P(dis) after pacing therapy.

CONCLUSIONS

Biatrial overdrive pacing is more effective in preventing post-CABG AF than single-site atrial pacing; this therapy also results in a shortened hospital stay. The overall reduction in atrial activation time with BiA pacing was reflected in the reduction in P(dis).

Pharmacology of coronary artery bypass grafts

Spasm of arterial and venous graft conduits can occur both during harvesting and after the graft is connected. Attempts to overcome spasm during harvesting by probing or hydraulic distension can cause structural damage to the graft, which may impair short- and long-term patency. After a coronary artery bypass graft is connected, spasm can cause major problems with myocardial perfusion. To select the best pharmacologic agent to prevent or reverse vasoconstriction in a graft requires an understanding of the reactivity of that particular type of graft to vasoconstrictor and vasodilator agents. The pharmacologic reactivity of venous and arterial graft conduits has been documented through extensive studies of isolated vessels in the organ bath and of in situ grafts in the body. In this review we summarize the current state of knowledge of the reactivity of arterial and venous grafts to vasoconstrictor and vasodilator agents and describe the practical application of this knowledge in the operating room and in the postoperative period.

Overview of the nature of vasoconstriction in arterial grafts for coronary operations

Many vasoconstrictors (spasmogens) may cause arterial graft spasm; however, there is lack of an overview of the nature of vasoconstriction in grafts. This study was designed to investigate the response of three major arterial grafts currently used for coronary artery bypass grafting to various vasoconstrictor substances. Segments of three arterial grafts (gastroepiploic [GEA], n = 28; internal mammary [IMA], n = 213; inferior epigastric [IEA], n = 24) taken from patients undergoing coronary artery bypass grafting were studied in organ baths under a physiologic pressure. Cumulative concentration-contraction curves were established for the following vasoconstrictor substances: endothelin-1, U46619, prostaglandin F2 alpha, norepinephrine, methoxamine, phenylephrine, 5-hydroxytryptamine, and potassium chloride (K+). In IMA, the highest contraction force was induced by U46619 (5.69 +/- 0.48 g), endothelin-1 (4.43 +/- 0.4 g), PGF2 alpha (6.29 +/- 1.42 g), and K+ (4.58 +/- 0.5 g). Internal mammary artery is highly sensitive to endothelin-1 (EC50, -8.13 +/- 0.08 log M) and U46619 (EC50, -8.21 +/- 0.21 log M) (lower than any other vasoconstrictors, p < 0.001). Next sensitive vasoconstrictors were PGF2 alpha and norepinephrine. 5-Hydroxytryptamine induced significantly higher contraction force in the IMA without endothelium (2.8 +/- 0.64 g versus 1.4 +/- 0.23 g, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of adrenoceptors in the human radial artery: clinical implications

OBJECTIVES

The radial artery has been suggested to be spastic. Endogenous and exogenous catecholamines and the use of beta-blockers may be related to radial artery spasm, but the characteristics of adrenoceptors in this artery are unknown. This study was designed to characterize the alpha- and beta-adrenoceptor in the human radial artery.

METHODS

Ring segments of the radial artery (n = 59) taken from patients undergoing coronary artery bypass grafting were studied in organ chambers. Alpha-adrenoceptor agonists (norepinephrine, methoxamine, and UK14304) and antagonists (phentolamine hydrochloride [INN: phentolamine], prazosin, and yohimbine) were used to characterize the alpha-adrenoceptor. Beta-adrenoceptor function was studied in U46619-precontracted rings in response to isoproterenol (INN: isoprenaline).

RESULTS

Norepinephrine induced 6.9 +/- 0.6 gm (80.6% +/- 6.8% of the contraction by 100 mmol/L KCl), and this was almost fully inhibited by phentolamine hydrochloride (10 micromol/L, p < 0.0001). The contraction force induced by methoxamine (2.9 +/- 0.8 gm) was abolished by 0.5 micromol/L prazosin (p = 0.017). The contraction force induced by UK14304 (1.7 +/- 0.4 gm) was abolished by 1 micromol/L yohimbine. In contrast to the porcine coronary artery used as the control (fully relaxed to isoproterenol), radial artery rings did not have significant relaxation (1.1% +/- 0.8%).

CONCLUSIONS

The human radial artery is an alpha-adrenoceptor-dominant artery with little beta-adrenoceptor function. The use of beta-blockers will not likely evoke the spasm of the radial artery. Furthermore, the radial artery has a dominant alpha1-adrenoceptor function, but the postjunctional alpha2-adrenoceptor is also functional. Circulating catecholamines will mainly contract the human radial artery by activation of the alpha1-adrenoceptors and to a lesser extent also by alpha2-adrenoceptors.

KDR (VEGF receptor 2) is the major mediator for the hypotensive effect of VEGF

Vascular endothelial growth factor (VEGF) exerts vasodilation-induced hypotension as a major side effect for treatment of ischemic diseases. VEGF has 2 receptor tyrosine kinases, KDR and Flt-1. Little is known about which receptor mediates VEGF-induced hypotension. To elucidate the role of each receptor in mediating hypotension, KDR-selective and Flt-1-selective mutants were used for in vitro and in vivo studies. The KDR-selective mutant induced vascular endothelial cell proliferation comparable to VEGF, whereas the Flt-1- selective mutant had no effect on proliferation. Intravenous injection of KDR-selective mutant, Flt-selective mutant, or VEGF caused a dose-related decrease in mean arterial pressure in conscious rats. The hypotensive response to KDR-selective mutant was significantly less than that to VEGF (P<0.01) but was greater than that to Flt-selective mutant (P<0.01). Similarly, VEGF and KDR-selective mutant induced more potent vasorelaxation than Flt-selective mutant or placenta growth factor that binds Flt-1 only (P<0.01), and the vasorelaxation to KDR-selective mutant was not significantly different at low concentrations but less than that to VEGF at high concentrations. The results indicate that the vasodilation and hypotensive effect of VEGF may involve both receptors, but KDR is the predominant receptor mediating this effect. Because KDR-selective mutant induced proliferation and angiogenesis similar to VEGF but was associated with 36% attenuation in hypotension, the data suggest that the KDR-selective mutant may represent an alternative treatment for ischemic diseases.

Comparison of nitric oxide release and endothelium-derived hyperpolarizing factor-mediated hyperpolarization between human radial and internal mammary arteries

BACKGROUND

Arterial grafts for CABG have been used increasingly, and the radial artery (RA) has become a preferable graft, secondary to the internal mammary artery (IMA). In the present study, we investigated and compared NO release and endothelium-derived hyperpolarizing factor (EDHF)-mediated hyperpolarization for IMA and RA.

METHODS AND RESULTS

IMA and RA segments taken from CABG patients were placed in an organ chamber. An NO-sensitive electrode (to directly measure NO release) or intracellular glass microelectrode (to measure membrane potential) was used to study NO or EDHF in response to acetylcholine (ACh) and bradykinin (BK) before and after incubation with indomethacin (a cyclooxygenase inhibitor), N(G)-nitro-L-arginine (an NO synthase inhibitor), and oxyhemoglobin (an NO scavenger). The resting membrane potential of the smooth muscle cells of IMA and RA was -58+/-0.84 (n=61) and -61+/-1.3 (n=46) mV, respectively (P=0.03). BK-induced EDHF-mediated hyperpolarization in the IMA was significantly greater than that in RA (BK 10(-)(7) mol/L: -10.9+/-1.5 [n=7] versus -5.8+/-0.9 [n=6] mV, P=0.04). The basal (16.8+/-1.9 versus 11.1+/-1.0 nmol/L, n=12, P=0.02) and stimulated releases of NO in IMA were significantly greater for BK (44.3+/-4.0 versus 25.8+/-3.6 nmol/L, n=8, P=0.004) and lasting longer for ACh (9.5+/-2.0 versus 6.6+/-3.6 minutes, n=12, P=0.03) than those in RA.

CONCLUSIONS

The basal and stimulated releases of NO and EDHF-mediated hyperpolarization in the IMA are significantly greater than that in the RA. The lower capacity of NO release may contribute to the susceptibility of RA to the perioperative vasospasm and may have an impact on the long-term graft patency.

Use of verapamil and nitroglycerin solution in preparation of radial artery for coronary grafting

BACKGROUND

The radial artery (RA) has been used as an alternative arterial graft for coronary artery bypass grafting. This artery has been reported to be spastic; therefore, use of spasmolytic drugs (vasodilators) during the preparation of the RA is recommended. The combination of calcium antagonists and nitroglycerin (verapamil plus nitroglycerin, VG solution) has been suggested to be effective in other bypass grafts. This study was designed to investigate (1) the effect of the VG solution during preparation of the RA for coronary artery bypass grafting and (2) whether the effect would last for a prolonged period after topical use.

METHODS

Ring segments of the RA taken from coronary artery bypass grafting patients were studied in organ chambers at a physiologic pressure. The relaxation effect of VG (30 mumol/L verapamil and 30 mumol/L nitroglycerin, n = 5) or papaverine (30 mumol/L, n = 5) was recorded in K+ (25 mmol/L potassium chloride)-precontracted RA segments. Other segments taken from the RA were treated (n = 5) or not treated (n = 20, as the control) with the VG solution for 45 minutes before used for coronary artery bypass grafting. Both the VG-treated and nontreated segments were immersed in oxygenated Krebs solution and stored in a refrigerator at 4 degrees C for 24 hours. The contraction force to 100 mmol/L K+ was compared between the two groups.

RESULTS

The VG solution induced more rapid relaxation than papaverine (p < 0.05 from the first to the ninth minute). After 10 minutes, both solutions induced full relaxation. The contraction to K+ (100 mmol/L) in rings treated with VG solution for 45 minutes during operation was almost abolished 24 hours later (0.86 +/- 0.1 g). In contrast, the control segments (n = 20) taken from nontreated RA contracted with K+ to high force (5.0 +/- 0.6 g; p < 0.001).

CONCLUSIONS

The present study suggests that the combination of verapamil and nitroglycerin may provide a rapid onset, a complete relaxation, and a long-lasting vasorelaxant effect when used to prepare the RA for grafting. This study adds a new method to prevent RA spasm during coronary artery bypass grafting.

Risk factors for operative mortality and sternal wound infection in bilateral internal mammary artery grafting

To investigate risk factors for operative mortality and sternal infection in patients undergoing bilateral internal mammary artery grafting, we analyzed the data of 199 patients who underwent this procedure from January 1986 through June 1992. These patients were also compared with those who underwent only saphenous vein grafting (1664 cases) and those who underwent unilateral internal mammary artery grafting (3359 cases) during the same time frame. The operative mortality was 3.52% (7/199) in the patients having bilateral internal mammary artery grafting, 2.71% (91/3359) in those having unilateral internal mammary artery grafting, and 8.53% (142/1664) in the patients having saphenous vein grafting (p < 0.0001). The occurrence rate of sternal infections was 2.45% (5/199) for bilateral internal mammary artery grafting, 1.32% (13/1664) for saphenous vein grafting, and 1.19% (20/3359) for unilateral internal mammary artery grafting (p = 0.27). The univariate analysis revealed that age, history of congestive heart failure, emergency operation, ejection fraction, and aortic crossclamp time were significantly correlated with operative mortality and that obesity was correlated with sternal wound infection. Stepwise multiple logistic regression identified that old age (> or = 70 years) (p < 0.0001), long perfusion time (p < 0.0001), and emergency operation (p = 0.0004) are risk factors for operative mortality and that obesity (p = 0.0009) is the only significant risk factor for sternal wound infection. We conclude that bilateral internal mammary artery grafting does not increase operative mortality in properly selected patients. However, this procedure should be carefully chosen in elderly (> or = 70 years) patients and for emergency operation. Obese patients have a high risk for sternal infection after bilateral internal mammary artery grafting.

Verapamil plus nitroglycerin solution maximally preserves endothelial function of the radial artery: comparison with papaverine solution

BACKGROUND

Endothelium plays a key role in graft patency. My colleagues and I have developed a verapamil+nitroglycerin solution (balanced to pH 7.4) to prepare the radial artery without mechanical distention or dilation and have reported the efficacy of its antispastic action. This study was designed to investigate whether using this solution as part of the University of Hong Kong protocol to prepare the radial artery is more efficacious than papaverine solution in preserving endothelial function.

METHODS

Ring segments of the radial artery taken from 25 patients undergoing coronary artery bypass grafting were studied in organ chambers. The endothelium-dependent relaxation, as the index of endothelial function, was examined by two mechanisms-receptor-mediated relaxation (by acetylcholine) and non-receptor-mediated relaxation (by calcium ionophore A23187) in U46619-induced contraction (10 nmol/L).

RESULTS

In the relaxation induced by either acetylcholine (27.3% +/- 5.0% [n = 7] vs 23.9% +/- 3.9% [n = 6],p = 0.6) or A23187 (62.9% +/- 6.0% [n = 13] vs 62.3% +/- 8.4% [n = 6],p = 0.96), there was no significant difference between the control radial arteries and those treated with the verapamil+nitroglycerin solution. In the papaverine-treated rings, acetylcholine-mediated relaxation was abolished (3.3% +/- 2.6% vs 23.9% +/- 3.9%,p < 0.001) and A23187-mediated relaxation was significantly reduced (39.7% +/- 5.2% vs 62.3% +/- 8.4%, p = 0.02) compared with verapamil+nitroglycerin treatment.

CONCLUSION

Use of verapamil+nitroglycerin solution to prepare the radial artery maximally preserves endothelial function. In contrast, papaverine impairs this function. Verapamil+nitroglycerin solution may be effectively and safely used to prepare the radial artery for coronary artery bypass grafting.

Up to thirty-year survival after aortic valve replacement in the small aortic root

Aortic valve replacement (AVR) in the small aortic root has been reported to be associated with obstruction of left ventricular output. This study was designed to investigate the determinants of long-term survival after the implantation of small size prostheses. From September 1961 to December 1993, 2,977 patients underwent isolated aortic valve replacement at our institution. Of these patients, 447 who were older than 18 years received small size (21 mm or less) prostheses. Long-term survival was investigated in the 404 patients who survived operation (more than 30 days) with 92% follow-up completeness (mean +/- deviation 7.1 +/- 6.4; maximum, 31 years). The age was younger than 50 years in 62 patients, 50 to 59 years in 60, 60 to 69 years in 99, 70 to 79 years in 138, and 80 to 94 years in 45; 67% were men. Thirty patients (7%) had previous AVR. Prosthesis usage included early Starr-Edwards models in 130 (32%), current Starr-Edwards (model 1260 since 1969) in 50 (12%), Carpentier-Edwards (porcine) in 113 (28%), and other prostheses in 111 patients (27%). One hundred sixteen patients (26%) had concomitant coronary artery bypass grafting (CABG). Eleven variables (age divided as above, sex, preoperative functional class, body surface area [BSA], small BSA [less than 1.6, 1.7, 1.8, or 1.9 m2], period of operation, previous AVR, type of prosthesis, size of prosthesis, concomitant CABG, and re-replacement) were investigated with regard to the long-term survival by the Kaplan-Meier method, and age, concomitant CABG, and type of prosthesis were significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal high-fat diet impacts endothelial function in nonhuman primate offspring

OBJECTIVE

The link between maternal under-nutrition and cardiovascular disease (CVD) in the offspring later in life is well recognized, but the impact of maternal over-nutrition on the offspring's cardiovascular function and subsequent risk for CVD later in life remains unclear. Here, we investigated the impact of maternal exposure to a high-fat/calorie diet (HFD) during pregnancy and early postnatal period on endothelial function of the offspring in a nonhuman primate model.

METHODS

Offspring, naturally born to either a control (CTR) diet (14% fat calories) or a HFD (36% fat calories) consumption dam, were breast-fed until weaning at about 8 months of age. After weaning, the offspring were either maintained on the same diet (CTR/CTR, HFD/HFD), or underwent a diet switch (CTR/HFD, HFD/CTR). Blood samples and arterial tissues were collected at necropsy when the animals were about 13 months of age.

RESULTS

HFD/HFD juveniles displayed an increased plasma insulin level and glucose-stimulated insulin secretion in comparison with CTR/CTR. In abdominal aorta, but not the renal artery, acetylcholine-induced vasorelaxation was decreased remarkably for HFD/HFD juveniles compared with CTR/CTR. HFD/HFD animals also showed a thicker intima wall and an abnormal vascular-morphology, concurrent with elevated expression levels of several markers related to vascular inflammation and fibrinolytic function. Diet-switching animals (HFD/CTR and CTR/HFD) displayed modest damage on the abdominal vessel.

CONCLUSION

Our data indicate that maternal HFD exposure impairs offspring's endothelial function. Both early programming events and postweaning diet contribute to the abnormalities that could be reversed partially by diet intervention.

Endothelium-dependent hyperpolarization and relaxation resistance to N(G)-nitro-L-arginine and indomethacin in coronary circulation

OBJECTIVE

It is controversial whether endothelium-dependent relaxation resistance to inhibitors of nitric oxide (NO) and prostacyclin synthases is completely attributed to endothelium-derived hyperpolarizing factor (EDHF). This study examined NO release and K+ channels involved in endothelium-dependent relaxation and hyperpolarization resistance to N(G)-nitro-L-arginine (L-NNA) and indomethacin in coronary arteries with emphasis on the microarteries.

METHODS

NO release, isometric force, and membrane potential of porcine coronary arteries were measured using a NO-specific electrode, wire myograph, and microelectrode, respectively.

RESULTS

In large arteries pretreated with indomethacin, bradykinin (BK) evoked a rise in [NO] from 5.5+/-2.4 nM to 105.0+/-19.6 nM and hyperpolarization. L-NNA treatment significantly reduced the BK-stimulated rise in [NO] to 32.1+/-11.3 nM but did not affect the hyperpolarization. In the presence of indomethacin and L-NNA, U46619 contracted and depolarized (from -51+/-3 mV to -30+/-4 mV) vascular smooth muscle in microarteries. The addition of BK produced dose-dependent relaxation (maximal: 70.2+/-5.7%) and repolarization (membrane potential: -50+/-4 mV). Oxyhemoglobin eliminated indomethacin and L-NNA-resistance rise in [NO] but not relaxation (42.3+/-4.4%) and repolarization (-40+/-2 mV) by BK. Tetraethylammonium, charybdotoxin, and iberiotoxin partially decreased the BK-induced responses. Apamin alone did not affect the relaxation by BK; however, in combination with charybdotoxin it almost completely abolished the BK-induced relaxation and hyperpolarization.

CONCLUSIONS

In porcine coronary arteries, both EDHF and NO contribute to BK-induced relaxation resistance to indomethacin and L-NNA. Large conductance Ca2+-activated K+ channels (BK(Ca)) may play an important role in mediating the BK-induced responses and small conductance Ca2+-activated K+ channels might function as 'backup' mechanisms when BK(Ca) is curtailed.

Valve repair for aortic insufficiency: surgical classification and techniques

OBJECTIVE

Valve repair for aortic insufficiency may provide an alternative to aortic valve replacement in selected patients. This repair could be an attempt at permanent correction or palliation to allow the aortic annulus to grow and avoid the use of anticoagulation. Based upon a five-year experience, we proposed a classification according to valvular anatomy which could be a guide to patient and procedure selection.

METHODS

Between September 1989 and February 1995, 44 consecutive patients underwent aortic valvuloplasty for aortic incompetence at our institution. Patients' ages ranged from 19 months to 76 years with a mean of 33 years. The etiology of aortic incompetence was congenital in 30 patients, degenerative in 7 patients, rheumatic in 5 patients, and infective endocarditis in 2. Aortic valve lesions were classified into three different types: type I, aortic annular dilation (8 patients); type II, excessive aortic leaflet tissue (12 patients); and type III, restricted leaflet motion with or without deficient leaflet tissue (24 patients). Type I needed commissural plication in 7 patients; and aortic annuloplasty, which was simple in 6 patients, and pericardial-augmented in 2. Type II necessitated midleaflet excision in 11 patients and leaflet plication in 7. Type III required leaflet extension in 19 patients, leaflet replacement in 1 patient, aortic valve commissurotomy in 13 patients augmentation commissurorrhaphy in 2, leaflet shaving in 4, and repair of leaflet perforation in 2.

RESULTS

Postoperative echocardiography revealed a significant decrease in the degree of aortic incompetence. Mean follow-up was 2.6 +/- 1.4 years. There was no mortality. Patients improved as is evident by NYHA functional class postoperatively. Eight of the first 13 patients (18%) needed reoperation. Three of these reoperations were bail-out procedures, and 3 patients (7%) who underwent the leaflet extension technique were reoperated upon 19 months to 3 years later. Presently, 23 patients are without anticoagulation, 11 take aspirin and 2 receive coumadin for combined mitral procedures.

CONCLUSIONS

Aortic valve repair provides a low risk option with satisfactory intermediate-term results for the treatment of aortic insufficiency in appropriately selected patients. Patient and procedure selection may be based upon the echocardiographic anatomy of the aortic valve, and a comparative risk benefit appraisal with valve replacement.

Contractility of the human internal mammary artery at the distal section increases toward the end. Emphasis on not using the end of the internal mammary artery for grafting

The distal section of the internal mammary artery (3 to 4 cm proximal to the bifurcation) is often used for coronary grafting. This part of the artery is more pharmacologically responsive to vasoconstrictor agents than is its midsection. The present study was designed to test the hypothesis that the reactivity of the distal section of the internal mammary artery is inversely correlated to the diameter of the artery. The distal section of the human internal mammary artery was collected from aorta-coronary bypass grafts and studied in organ baths at a length of 3 mm. At the optimal point of the length-tension curves determined by a computer-iterative fitting technique, the diameter at 100 mm Hg, the maximal contraction forces and effective concentration causing 50% of the maximal response to vasoconstrictor agents U46619, potassium chloride, alpha-adrenoceptor agonists norepinephrine, methoxamine, and phenylephrine were recorded or calculated. The maximal relaxation and 50% response to glyceryl trinitrate in phenylephrine-precontracted internal mammary artery segments were also calculated. The contraction force was standardized by the circumference (grams per millimeter). Regression analysis between contraction force and diameter revealed that the contraction force induced by U46619 and potassium chloride was inversely correlated to diameter (r2 = 0.2, p < 0.05 in U46619-induced contraction and r2 = 0.2, p < 0.01 in potassium chloride-induced contraction). The contraction force induced by norepinephrine also had a trend inversely correlated to diameter (r2 = 0.2, p = 0.07). Glyceryl trinitrate-induced relaxation was not correlated to diameter. This study demonstrated that the contractility of the distal section of the internal mammary artery is inversely correlated to the diameter; that is, the smaller the diameter, the greater the tendency for spasm to develop. This suggests that trimming off the distal end of the internal mammary artery as much as possible may be the best way to prevent graft spasm and that superior results of left internal mammary artery grafted to the left anterior descending artery or the use of a "free graft" may be related to the shorter length (distal end is trimmed off) and less contractility of the graft.

Determinants of operative mortality in reoperative coronary artery bypass grafting

Previously suggested risk factors for operative mortality in reoperative coronary artery bypass grafting are contradictory. Therefore, we analyzed our data of 622 patients who underwent reoperative bypass grafting from January 1986 through June 1993. Among these patients, 258 had saphenous vein grafts alone and 364 had internal mammary artery grafting, including unilateral (342 patients) and bilateral (22 patients) mammary artery grafting with or without additional saphenous vein grafting. Overall operative mortality was 11.4% for reoperation compared with only 3.6% for primary bypass grafting during the same time frame. To determine risk factors for mortality and the influence of internal mammary artery grafting on the outcome, we analyzed 82 variables (31 preoperative, 17 intraoperative, and 34 postoperative) by univariate analysis. Significant variables or the variables having a trend (p < 0.2) to be associated with the mortality were included in stepwise multiple logistic regression analyses. Two regression analyses were separately performed. Regression 1 only included preoperative and intraoperative variables whereas regression 2 included postoperative variables as well. The logistic regressions demonstrate that preoperative variables (low ejection fraction [p = 0.0002], old age [p = 0.003], female gender [p = 0.011], and history of arrhythmia [p = 0.023]), intraoperative variables (emergency operation [p = 0.0001] and long perfusion time [p = 0.0001]), and postoperative variables (complications) are independently associated with higher mortality. Unlike previously described results, aortic crossclamp time, route of cardioplegia, use of internal mammary artery, number of grafts, and year of operation are not associated with operative mortality. The identification of these risk factors may have important implications in further improvement of the results of reoperative coronary artery bypass grafting.

Urocortin-induced endothelium-dependent relaxation of rat coronary artery: role of nitric oxide and K+ channels

1. The mechanisms underlying the vasodilator response to urocortin are incompletely understood. The present study was designed to examine the role of endothelial nitric oxide and Ba(2+)-sensitive K(+) channels in the endothelium-dependent component of urocortin-induced relaxation in the rat left anterior descending coronary artery. 2. Urocortin induced both endothelium-dependent and -independent relaxation with respective pD(2) of 8.64+/-0.03 and 7.90+/-0.10. Removal of endothelium reduced the relaxing potency of urocortin. In rings pretreated with 10(-4) M N(G)-nitro-L-arginine methyl ester, 10(-5) M methylene blue or 10(-5) M ODQ, the urocortin-induced relaxation was similar to that observed in endothelium-denuded rings. L-Arginine (5x10(-4) M) antagonized the effect of N(G)-nitro-L-arginine methyl ester. 3. The relaxant response to urocortin was reduced in endothelium-intact rings preconstricted by 3.5x10(-2) M K(+) and abolished when extracellular K(+) was raised to 5x10(-2) M. Pretreatment with 10(-4) M BaCl(2) significantly inhibited urocortin-induced relaxation. Combined treatment with 10(-4) M BaCl(2) plus 10(-4) M N(G)-nitro-L-arginine methyl ester did not cause further inhibition. In urocortin (10(-8) M)-relaxed rings, BaCl(2) induced concentration-dependent reversal in vessel tone. Tertiapin-Q (10(-6) M) also attenuated urocortin-induced relaxation. In contrast, BaCl(2) did not alter urocortin-induced relaxation in endothelium-denuded rings. 4. In endothelium-denuded rings, hydroxylamine- and nitroprusside-induced relaxation was inhibited by 10(-4) M BaCl(2), but not by 10(-6) M tertiapin-Q. 5. The endothelium of the coronary artery was moderately stained with the antiserum against urocortin. 6. Taken together, the present results indicate that the urocortin-induced endothelium-dependent relaxation of rat coronary arteries is likely attributable to endothelial nitric oxide and subsequent activation of Ba(2+)- or tertiapin-Q-sensitive K(+) channels. The urocortin-induced endothelium-dependent relaxation appears to be mediated by cyclic GMP-dependent mechanisms.

Pharmacological relaxation of the saphenous vein during harvesting for coronary artery bypass grafting

Spasm of the saphenous vein frequently occurs during harvesting from the leg and high-pressure distension is required to restore an adequate diameter for grafting. Forceful distention has been shown to damage the intima and media and may predispose to subsequent occlusion of the vein graft. Various pharmacologic vasodilators are capable of relaxing veins; in this study, we carried out a systematic investigation to determine the appropriate agents and concentrations for use during vein graft operations. In organ baths, human saphenous vein segments were contracted with potassium or a thromboxane mimetic, and vasodilator agents were then applied. Glyceryl trinitrate, 7.2 micrograms/mL, or papaverine hydrochloride, 11.9 micrograms/mL, caused 80% to 100% relaxation of contraction induced by potassium or thromboxane. Verapamil, 15.5 micrograms/mL, relaxed the potassium contraction by 100% and the thromboxane contraction by 75%. Comparison of the time course of action showed that glyceryl trinitrate had a rapid onset and a short duration of maximal action, whereas verapamil (like papaverine) had delayed onset and a long duration. A mixture of glyceryl trinitrate and verapamil combined rapid onset with long duration of action. We now use a mixture of glyceryl trinitrate and verapamil (pH 7.4) topically and intraluminally during harvesting of the saphenous vein to provide a relaxed conduit for coronary artery bypass grafting.