Myocardial revascularization without extracorporeal circulation. Seven-year experience in 593 cases

The authors present the results of 593 consecutive and non-selected patients who underwent direct myocardial revascularization without extracorporeal circulation in the period September 1981 to December 1988. The results are compared with 3086 patients who underwent conventional bypass surgery over the same period of time. The ages varied from 33 to 80 years (mean = 56) with 40 patients older than 70. The overall mortality in the group without cardiopulmonary bypass (CPB) was 1.7% (10/593) compared with 3.8% for conventional revascularization. Our mortality in the last 3 years has been 0.5% and 0% in the last 203 patients revascularized without CPB. The number of grafts varied from 1 to 5 (average 1.6). The treated arteries were: anterior descending (557), right (282) marginal (5) and circumflex marginal (4). Immediate postoperative complications were fewer and hospital discharge was earlier in the group treated without CPB. The authors conclude that this tactical alternative has the advantages of: lower morbidity and mortality, lower cost and no need for blood transfusion. Drawbacks are the need for greater technical expertise and it seems to be possible in about 19% of all patients who undergo myocardial revascularization.

Serum ferritin and hemochromatosis alleles in chronic hemodialysis patients

There have been some reports on the risk of developing hemosiderosis in hemodialysis patients when heavily transfused and simultaneously possessing hemochromatosis alleles (HA). We evaluated 99 patients on chronic hemodialysis estimating their serum ferritin (SF) levels, transfusion rate, and prevalence of HLA A3, B7 and B14 alleles, which are considered to be more frequent in idiopathic hemochromatosis. We analyzed the patients as a whole group and also separately as low or high transfusion groups. There was no correlation between the number of HA and the mean SF levels. The presence of HA is not a risk factor for the development of hemosiderosis when excessive transfusions and parenteral iron administration are avoided.

Modified Blalock-Taussig shunt with an umbilical vein graft

We describe a modification of the Blalock Taussig anastomosis, with the interposition of a glutaraldehyde-tanned umbilical vein graft between the subclavian and pulmonary arteries. This operation was performed in 64 children: 11 were less than 1 month of age (17.2%), and 23 were between 1 and 6 months of age (34.9%). Hospital deaths occurred in six patients-all less than 6 months of age (9.4%). There was no instance of shunt occlusion noted. The clinical course was uneventful among survivors, except for one patient who died of endocarditis in the late postoperative follow-up. The shunt procedure may be performed very rapidly, with minimal dissection, allowing the use of a graft larger than the diameter of the subclavian artery. This modification of the Blalock Taussig operation compares favorably with our previous experience with other shunt procedures and may be considered a valuable alternative in the palliative surgical treatment of several malformations with severe pulmonary oligemia.

Direct myocardial revascularization without extracorporeal circulation: technique and initial results

In a 10-month period, 68 patients underwent saphenous vein bypass revascularization without extracorporeal circulation. Distal sutures were performed with interruption of coronary flow without any devices for perfusion of the coronary artery; the proximal sutures were completed with tangential clamping of the aorta. Most frequently, the anterior descending and the distal right coronary arteries were revascularized; of 225 patients who underwent bypass surgery, this technique was possible in 68 cases (30.2%). The 30-day hospital mortality was 1.5%, and perioperative myocardial infarction, as determined by daily electrocardiograms (ECGs) and creatine phosphokinase isoenzyme (CKMB), occurred in two patients. Control hemodynamic studies were performed in 22 of the 68 patients (32.4%) with a patency rate of 84.2% in the grafts restudied.

Direct myocardial revascularization without cardiopulmonary bypass

The authors present their experience with 160 patients who underwent coronary artery saphenous vein bypass revascularization without cardiopulmonary bypass. The distal sutures were performed with interruption of the coronary flow without any devices for perfusion of the coronary artery: the proximal sutures were made with tangential clamping of the aorta. Vessels most frequently revascularized were the anterior descending and the distal right coronary artery. Out of 597 patients who underwent bypass surgery in this period, this technique could be employed in 160 cases (26.8%). Hospital mortality was 3.1% (5/160) and perioperative myocardial infarction as determined by daily EKGs and CKMB occurred in 4 patients (2.5%). Control hemodynamic studies were performed in 41 of the 160 patients (25.6%) with a patency rate of 83.9% in the 62 grafts restudied. We conclude that direct myocardial revascularization can be performed safely without major difficulties and with efficient anastomoses. The main advantages of the technique are that it does not require the use of extracorporeal circulation and, consequently, the use of any blood, as well as its low cost due to shorter hospitalization periods.

Surgical treatment of endomyocardial fibrosis

Thirty patients with endomyocardial fibrosis were submitted to endocardial decortication and atrioventricular valve replacement between December, 1977, and October, 1981. There were 26 female and four male patients, ranging in age from 14 to 48 years (mean 32). Thirteen patients had biventricular disease, 14 had the right-sided form, and three had endomyocardial fibrosis confined to the left ventricle. All were in Functional Class III or IV (New York Heart Association classification). The hospital mortality was 20% (six cases). Among the survivors (mean follow-up 13 months), 23 of 24 were improved clinically. Postoperative hemodynamic and angiographic studies were performed in 15 patients. Two (6.6%) have definitive atrioventricular heart block. There were five (16.6%) late deaths. Operation for endomyocardial fibrosis should be considered a palliative procedure. Possible limitations include the need for a valve prosthesis, cardiac conduction disturbances secondary to endocardiectomy of the right ventricle, and the possibility of recurrence of the endocardial fibrosis. However, at present, operation seems to be the treatment of choice for this condition because (1) endomyocardial fibrosis is characterized by a grave prognosis and medical therapy is ineffective; (2) endomyocardial fibrosis is a disease in which only the heart is affected, lesions in other organs being the result of passive congestion; (3) systolic performance of the heart is usually only slightly depressed; and (4) the surgical procedure is easily performed, so that the mortality is acceptable.

Endomyocardial fibrosis: report of 6 patients and review of the surgical literature

Six patients with endomyocardial fibrosis were treated by endocardium decortication and atrioventricular valve replacement. There were 5 female patients and 1 male patient ranging from 14 to 48 years old (mean, 30 years). Four patients had involvement of the right ventricle, 1 patient had involvement of the left ventricle, and 1 patient had biventricular disease. There was 1 operative death due to low cardiac output state (the patient with biventricular endomyocardial fibrosis), and there was 1 late noncardiac death. The surgical literature, which describes 19 previously reported cases, was reviewed. On the basis of the results of this series and those of the reported cases, it is concluded that surgical treatment of endomyocardial fibrosis is feasible and provides good clinical improvement.