Patient care problems in patients undergoing reoperation for coronary artery grafting surgery

The First Cardiac Anesthesiology Fellow, William A. Lell: A Brief History

Fifty years ago, on August 1, 1971, William A. Lell became the first cardiac anesthesia fellow at Harvard's Massachusetts General Hospital (MGH) Department of Anesthesiology, training with the world's first group of anesthesiologists whose clinical practice, teaching, and research efforts were exclusively devoted to cardiac anesthesia. Lell's early interest in cardiovascular medicine and how mentors, particularly at the MGH, influenced his early career development are recounted. The challenges a young pioneer faced in establishing and maintaining an academic cardiac anesthesia program during the initial and rapid growth of an exciting new subspecialty are described. Dr Lell's experience emphasizes the importance of seizing new opportunities and establishing meaningful working relationships with colleagues based on mutual trust as fundamental to successful career development and research in a new medical subspecialty.

Selecting a Vasopressor Drug for Vasoplegic Shock After Adult Cardiac Surgery: A Systematic Literature Review

The choice of vasopressors to treat vasodilatory shock after cardiac surgery is a matter of controversy. We have systematically reviewed the literature and found that the data are insufficient to guide choice of agent. However, we found sufficient evidence that when a target blood pressure can not be achieved with a single agent, addition of another is more likely to help achieve the blood pressure target. We also found that there is no evidence that vasopressors induce organ ischemia. Finally, the lack of high quality data indicate that large multicenter trials are needed in this field.

Myocardial revascularization for the third time. Clinical characteristics and follow-up

Twenty-five patients presenting for a third revascularization procedure were retrospectively reviewed at Loyola University Medical Center, Maywood, IL. This represents 0.5 percent of the total revascularization cases over a five-year period extending from 1985 through 1989. Perioperative mortality was none, and seven complications occurred in six patients. Internal mammary arteries were used for revascularization in 60 percent of this group. Follow-up reveals that only one patient has died secondary to an arrhythmia. All patients except one are symptomatically improved, and 18 patients remain angina free at a mean follow-up of 22.3 months. It is therefore concluded that patients are clinically improved with a third revascularization, and this procedure should be offered as an effective means of treatment.

Reoperation for coronary artery bypass grafting: anesthetic challenge

The problem of caring for patients undergoing reoperative coronary revascularization is one that cardiac anesthesiologists will face with increasing frequency. Many thousands of CABG procedures continue to be performed annually with ever-increasing survival rates. Consequently, the population at risk for reoperative CABG is growing, while surgical intervention necessarily follows apace. As one recent long-term, retrospective study showed, patients surviving 12 years after CABG have a reoperative rate of 17.3%. Physicians caring for these patients must recognize that they are not seeing patients with routine CAD, but with a different entity: coronary graft disease (CGD). These patients with CGD are different in many ways from those with native CAD, and these differences must be taken into account when planning for their perioperative care. Cardiologists have strived to check the growth of CGD by aggressive emphasis on modification of coronary risk factors such as tobacco use, hypertension, and hyperlipidemia. In addition, recent interest has been focused on a pharmacologic approach via the platelet-prostaglandin system. Surgeons have also attempted to reduce the incidence of CGD by recognition that significantly improved long-term patency rates can be achieved by the use of the internal thoracic artery as a bypass conduit. Consequently, an expanded role for this vessel in the form of free, sequential, and bilateral ITA grafting is currently being advocated as a surgical solution to the problem of CGD. In contrast, the anesthesiologist probably has little to add to the prevention of CGD, but may be able to contribute to a favorable outcome at reoperation. The medical variables and preoperative characteristics that make reoperative CABG patients different from those presenting for primary CABG should be recognized. A firm appreciation of the nature of graft disease, as well as the surgical intricacies required for correction, can only serve to improve the care offered during these often complex operations. Aggressive, invasive hemodynamic monitoring, constant vigilance for signs of early ischemia, and preparedness for prebypass hemorrhage and postbypass ventricular dysfunction should be made. Furthermore, if anesthesiologists are to contribute to an improved outcome in these patients, strategies must be developed to attenuate cerebral and myocardial damage resulting from hemorrhage and atheroembolic catastrophies that appear to be frequent complications in these challenging surgical patients.

Clinical response to coronary artery reoperations

Repeat coronary artery bypass operations were performed on 112 patients at a university hospital between 1971 and 1981. When compared with patients who did poorly after a first operation but did not have repeat surgery, patients undergoing repeat surgery tended to be younger, to have a higher smoking rate and to have fewer prior myocardial infarctions, fewer diseased vessels and fewer lesions in distal vessels. At least 1 graft was occluded in 83% of patients undergoing reoperation, and a mean of 1.7 grafts were placed at reoperation. The operative mortality rate was 4%, with a follow-up mortality rate of 6% at a mean of 3.8 years. After reoperation, patients initially showed improvement to a mean specific activity scale class of 1.6, compared with 2.4 before the first operation and 2.7 before the second operation. The principal correlate of a better long-term symptomatic response compared with that in the period before the first operation was a lower serum cholesterol level, whereas the principal correlate of a better symptomatic response compared with that in the period just before the reoperation was the left ventricular ejection fraction. As recurrent symptoms after a first coronary artery operation become more prevalent, consideration of the selection factors and prognostic correlates of reoperation will become increasingly important.