Disseminated intravascular clotting associated with Fc-receptor IIa-mediated platelet activation in a patient with endocarditis after aortic valve replacement

This report describes fatal disseminated cardiovascular thrombosis associated with Fc-receptor IIa-mediated platelet activation during surgery for aortic valve replacement in a patient with endocarditis. The patient's serum contained antibodies which strongly activated platelets via the Fc-receptor IIa. Antibodies did not bind to platelet factor 4 or aprotinin and binding was independent of heparin. The mechanisms and differential diagnosis for such a complication are discussed. Our data show for the first time in a patient with endocarditis that, beside HIT, other immune complexes can induce massive intravascular coagulation via platelet Fc-receptor IIa activation.

Intraoperative coronary graft flow determination--does it have a prognostic value for midterm graft patency?

OBJECTIVE

To characterise the prognostic value of intraoperative ultrasonic graft flow determination during CABG for mid-term patency.

METHODS

From 01/2000 to 08/2003 3146 CABG procedures were performed at our institution. Graft flow was determined in all patients. Lumen diameter was given in mm and a sclerosis score was applied for the target vessel. 100 of these patients (3.2%) underwent postoperative coronary angiography at a mean time interval of 8.0 +/- 0.5 months.

RESULTS

In 100 patients, 114 LITA and 204 venous anastomoses were performed. At re-angiography 112 LITA (98%) and 174 venous (85%) anastomoses were patent. The amount of occluded LITA grafts was to low to perform statistical analyses. Mean graft flow of patent vein grafts was 48 +/- 2 ml/min vs. 32 +/- 4 ml/min in occluded vein grafts (p = 0.001). After multiple logistic regression analysis, only intraoperative vein graft flow was found to be a predictor for patency at mid-term (p = 0.005, odds ratio 0.97, 95% confidence interval (CI) from 0.95-0.99). No differences were found concerning sclerosis scores or vessel lumen between patent and occluded grafts.

CONCLUSIONS

Significant differences concerning intraoperative graft flow were found between vein grafts patent or occluded at re-angiography. The predictive power of intraoperative vein graft flow for mid-term patency was confirmed by multiple logistic regression analysis.

Off pump coronary artery bypass grafting - midterm results

OBJECTIVE

Off pump coronary artery bypass (OPCAB) grafting is still discussed controversially in the cardiac surgical community. Early perioperative results are encouraging. Only few reports have focused on mid-term recurrence of angina and freedoms from death or re-intervention. -

METHODS

107 OPCAB patients (mean age 63 +/- 1 years, 77 male, log EuroScore 5.6 +/- 0.7, number of distal anastomoses 2.0 +/- 0.1), operated on between January 1999 and December 2003, were systematically followed up comparing pre- and post-op NYHA- and CCS-classifications and assessing freedom from death and re-intervention. 52 of 107 patients underwent postoperative angiography or multi-slice computed tomography (MSCT); 6 of the latter 52 patients were symptomatic, 3 with unstable angina, the others underwent follow-up studies having given their informed consent. -

RESULTS

The 30 day mortality was 2%. Freedom from death or re-intervention at 5.5 years was 91% and 80%, respectively. Only three patients required re-intervention in an OPCAB-related vessel. CCS classification was 2.8 +/- 0.1 before surgery and 1.8 +/- 0.2 (p<0.01) at follow-up (3.3 +/- 0.3 years). NYHA classification was 2.7 +/- 0.1 and 2.2 +/- 0.1 (p<0.01), respectively. Out of 107 patients, 52 underwent coronary angiography or MSCT (6 for cardiac symptoms) at a mean follow-up of 2.2 +/- 0.3 years. Left internal thoracic artery was patent in 91%, venous graft patency rate was 83%. -

CONCLUSIONS

In this small but consecutive OPCAB population with a considerable perioperative risk according to the EuroScore, freedom from death and re-intervention at 5.5 years is acceptable and graft patency rate at 2.2 +/- 0.3 years is in the expected range. Significant reduction in both CCS and NYHA classification indicate sustained clinical improvement at mid-term.

Impact of intraoperative myocardial cellular damage on early hemodynamics after off-pump versus on-pump coronary artery bypass surgery

BACKGROUND

Due to the surgical trauma a small amount of myocardial cellular damage is inherent during coronary artery bypass grafting (CABG). The purpose of the present study was to assess the degree of myocardial cellular damage after off-pump (OPCAB) and on-pump CABG (ONCAB) as measured by cardiac troponin I (cTnI), creatine kinase (CK), its MB isoenzyme (CK-MB) and myoglobin (Myo) and to examine its impact on early hemodynamics after surgery.

METHODS

Ninety-nine consecutive OPCAB patients, operated between 01/1999 and 01/2004, were enrolled in the present study and compared to 99 ONCAB patients operated during the same period of time, who were matched for baseline data and mean number of grafts per patient. Early hemodynamics, cTnI, CK/CK-MB and Myo were measured preoperatively and at 1, 6, 12, 24 and 48 hours (h) postoperatively. Perioperative inotropic support, clinical data and potoperative outcome were recorded prospectively.

RESULTS

The two groups were similar concerning preoperative characteristics. The mean number of distal grafts/patient was 2.1 +/- 1.0 in OPCAB and 2.1 +/- 0.8 in ONCAB patients (mean +/- SD). There was no significant difference among the groups regarding early hemodynamics in terms of cardiac index (CI), systemic vascular resistance index (SVRI), and left ventricular stroke work index (LVSWI), and inotropic support. However, cTnI, CK/CK-MB but not Myo levels were significantly lower in OPCAB compared to ONCAB patients at 1, 6, 12, 24, 36 and 48 h postoperatively (P<0.05).

CONCLUSIONS

Off-pump surgery results in equal early hemodynamics despite a significantly lower release of cTnI and CK, suggesting a reduced myocardial cell damage as compared to ONCAB surgery.