An 11 year evolution of coronary arterial surgery (1968-1978)

All patients who underwent isolated myocardial revascularization procedures from 1967-70 (n = 741) were compared with the first 1,000 patients who received similar elective operations each year from 1971 through 1978. Data from these eight years were processed through a computerized cardiovascular information registry. Median age increased from 50 to 56 years, multiple-vessel disease increased from 44 to 89%, and left ventricular asynergy from 41 to 54%. The number of grafts per patient increased from 1.5 to 2.5 and yet morbidity declined in every category except neurologic deficit. Operative mortality was 1.1% from 1967 through 1978 and 0.9% from 1971 through 1978. Graft patency was determined for 475 patients from 1967-70, 553 patients from 1971, 519 from 1972, and 540 from 1973. Patency rates after a mean catheterization interval of 21 months were 77, 77, 84, and 87% respectively. Higher graft patency coincides with introduction of the internal mammary artery graft. Five year follow-up was completed for the 1967-1970 series and 1971, 1972, and 1973 cohorts. Actuarial five year survival was 89.6, 91.6, 93.2, and 91.7%. Five year survival comparisons between 1967-1970 patients and 1971-1973 patients in single-, double-, and triplevessel disease categories show significant extended longevity in the later experience. Abnormal ventricular function and incomplete revascularization adversely influenced longevity (p < 0.05) in all years surveyed. In those series the percentage of asymptomatic patients at five years was 66, 65, 69, and 67%. Lower risk and higher five year survival are attributed to greater technical experience, changing technology, and improved management rather than to selection of lower risk cases.

Asymptomatic coronary artery disease managed by myocardial revascularization: results at 5 years

A consecutive series of 17 patients surgically treated for asymptomatic coronary artery disease was surveyed for survival, clinical status, and graft patency after a mean follow-up of 75 months. Documented myocardial infarction (MI), 14 transmural and 3 subendocardial, was the major indication for catheterization. All patients were asymptomatic for at least 4 months prior to surgery. Six patients had greater than 70% obstruction in one vessel, seven in two vessels, and four in three vessels. The indication for revascularization was critical stenoses in vessels supplying large areas of viable myocardium. All patients received left internal mammary artery (LIMA) grafts to the left anterior descending coronary artery; seven patients also received saphenous vein grafts (SVG) to other vessels. There was no operative or late mortality. In 12 patients, postoperative angiography (mean interval, 12 1/2 months) showed 11/12 LIMA and all SVG patent. One incompletely revascularized patient with an occluded LIMA is symptomatic. All others are fully active without symptoms or interval MI after a minimum follow-up of 5 1/2 years. The safety and long-term results of myocardial revascularization warrant its consideration for selected asymptomatic postinfarction patients.

Blood conservation during myocardial revascularization

A prospective study of blood utilization in 50 consecutive patients undergoing elective coronary artery bypass was undertaken. Blood was removed from all patients during induction of anesthesia and reinfused after bypass (mean, 675 ml). Intraoperatively, all discard suction was routed through a regionally heparinized collecting and processing system, and the resulting red cell concentrate was transfused. At the conclusion of bypass, all blood remaining in the pump oxygenator was retained for transfusion. After operation, shed mediastinal blood was collected in a sterile, filtered collection system and transfused. Normovolemic anemia was accepted in hemodynamically stable patients. The mean amount of patients' blood salvaged by the intraoperative system was 259 ml (range, 0 to 724 ml) and by the postoperative system, 194 ml (range, 0 to 564 ml). Ninety-four percent (47/50) of the patients received no bank blood or blood products during their hospital stay. No patients received bank blood intraoperatively or during the first 24 hours following operation. There were no complications attributable to blood salvage techniques.

Atherosclerosis of the left main coronary artery: 5 years results of surgical treatment

Three hundred consecutive patients received coronary arterial bypass grafts as treatment for stenosis of the left main coronary artery. Ostial stenosis was more prevalent among women (P less than 0.001). Operative (hospital) mortality was 4 percent (12 of 300). Among 148 survivors who underwent recatheterization after a mean interval of 16.5 months, the graft patency rate was 88 percent. After a minimal follow-up period of 49 months and a mean interval of 69 months, 75 percent of the survivors were asymptomatic and 94 percent were employed or fully active. The actuarial 5 year survival rate was 88.2 percent. The presence of right coronary artery disease, abnormal preoperative ventricular function and incomplete revascularization adversely affected survival, but the differences did not reach statistical significance. Comparison of this long-term follow-up study with controlled and noncontrolled studies of nonsurgical treatment of obstructions of the left main coronary artery indicates that myocardial revascularization alleviates cardiac symptoms and increases life expectancy in patients with severe atherosclerosis of this artery.

Autotransfusion following cardiac operations: a randomized, prospective study

To evaluate the safety and effectiveness of the collection and retransfusion of postoperatively shed mediastinal blood as part of a multifaceted approach to blood conservation following cardiac operation, 113 patients were randomized into either an autotransfusion group (54 patients) or a control group (59 patients). Intraoperative and postoperative hemodilution was practiced in all patients. The clinical safety of this technique was confirmed by the lack of septic, hematological, pulmonary, renal, or hepatic complications. However, in this setting where blood conservation is already aggressively practiced, the ability of the technique to further reduce the use of banked blood following cardiac surgical procedures was not demonstrated.