Home-Based, Adaptive Cognitive Training for Cognitively Normal Older adults: Initial Efficacy Trial

OBJECTIVES

We examined whether a home-based, adaptive cognitive training (CT) program would lead to cognitive performance changes on a neuropsychological test battery in cognitively normal older adults.

METHOD

Sixty-eight older adults (age = 70.0, SD = 3.74) were randomly assigned to either CT or an active control group (AC, casual computer games). Participants were instructed to train on their assigned programs for 42 min per day, 5 days per week, over 10 weeks (35 hr of total program usage). Participants completed tests of processing speed, working memory, and executive control before and after 10 weeks of training.

RESULTS

Training groups did not differ in performance before training. After training, CT participants out-performed AC participants in the overall cognitive composite score, driven by processing speed and working memory domains.

DISCUSSION

Our results show that a limited dose of home-based CT can drive cognitive improvements as measured with neuropsychological test battery, suggesting potential cognitive health maintenance implications for cognitively normal older adults.

Economic evaluation of highly purified human menotropin or recombinant follicle-stimulating hormone for controlled ovarian stimulation in high-responder patients: analysis of the Menopur in Gonadotropin-releasing Hormone Antagonist Single Embryo Transfer-High Responder (MEGASET-HR) trial

Objective

To determine the cost of achieving a live birth after first transfer using highly purified human menotropin (HP-hMG) or recombinant follicle-stimulating hormone (FSH) for controlled ovarian stimulation in predicted high-responder patients in the Menopur in Gonadotropin-releasing hormone Antagonist Single Embryo Transfer-High Responder (MEGASET-HR) trial.

Design

Cost minimization analysis of trial results.

Setting

Thirty-one fertility centers.

Patients

Six hundred and nineteen women with serum antimüllerian hormone ≥5 ng/mL.

Interventions

Controlled ovarian stimulation with HP-hMG or recombinant FSH in a gonadotropin-releasing hormone (GnRH) antagonist assisted reproduction cycle where fresh transfer of a single blastocyst was performed unless ovarian response was excessive whereupon all embryos were cryopreserved and patients could undergo subsequent frozen blastocyst transfer within 6 months of randomization.

Main Outcome Measures

Mean cost of achieving live birth after first transfer (fresh or frozen).

Results

First-transfer efficacy, defined as live birth after first fresh or frozen transfer, was 54.5% for HP-hMG and 48.0% for recombinant FSH (difference 6.5%). Average cost to achieve a live birth after first transfer (fresh or frozen) was lower with HP-hMG compared with recombinant FSH. For fresh transfers, the cost was lower with HP-hMG compared with recombinant FSH. The average cost to achieve a live birth after first frozen transfer was also lower in patients treated with HP-hMG compared with recombinant FSH.

Conclusions

Treatment of predicted high-responders with HP-hMG was associated with lower cost to achieve a live birth after first transfer compared with recombinant FSH.

Clinical Trial Registration Number

NCT02554279.

The effect of automated text messaging and goal setting on pedometer adherence and physical activity in patients with diabetes: A randomized controlled trial

INTRODUCTION

Activity-monitoring devices may increase activity, but their effectiveness in sedentary, diseased, and less-motivated populations is unknown.

METHODS

Subjects with diabetes or pre-diabetes were given a Fitbit and randomized into three groups: Fitbit only, Fitbit with reminders, and Fitbit with both reminders and goal setting. Subjects in the reminders group were sent text-message reminders to wear their Fitbit. The goal-setting group was sent a daily text message asking for a step goal. All subjects had three in-person visits (baseline, 3 and 6 months). We modelled daily steps and goal setting using linear mixed-effects models.

RESULTS

138 subjects participated with 48 in the Fitbit-only, 44 in the reminders, and 46 in the goal-setting groups. Daily steps decreased for all groups during the study. Average daily steps were 7123, 6906, and 6854 for the Fitbit-only, the goal-setting, and the reminders groups, respectively. The reminders group was 17.2 percentage points more likely to wear their Fitbit than the Fitbit-only group. Setting a goal was associated with a significant increase of 791 daily steps, but setting more goals did not lead to step increases.

CONCLUSION

In a population of patients with diabetes or pre-diabetes, individualized reminders to wear their Fitbit and elicit personal step goals did not lead to increases in daily steps, although daily steps were higher on days when goals were set. Our intervention improved engagement and data collection, important goals for activity surveillance. This study demonstrates that new, more-effective interventions for increasing activity in patients with pre-diabetes and diabetes are needed.

Improved Health-Related Quality of Life in a Phase 3 Islet Transplantation Trial in Type 1 Diabetes Complicated by Severe Hypoglycemia

OBJECTIVE

Attaining glycemic targets without severe hypoglycemic events (SHEs) is a challenging treatment goal for patients with type 1 diabetes complicated by impaired awareness of hypoglycemia (IAH). The CIT Consortium Protocol 07 (CIT-07) trial showed islet transplantation to be an effective treatment for subjects with IAH and intractable SHEs. We evaluated health-related quality of life (HRQOL), functional health status, and health utility before and after pancreatic islet transplantation in CIT-07 trial participants.

RESEARCH DESIGN AND METHODS

Four surveys, the Diabetes Distress Scale (DDS), the Hypoglycemic Fear Survey (HFS), the Short Form 36 Health Survey (SF-36), and the EuroQoL 5 Dimensions (EQ-5D), were administered repeatedly before and after islet transplantation. Summary statistics and longitudinal modeling were used to describe changes in survey scores from baseline and to characterize change in relation to a minimally important difference (MID) threshold of half an SD.

RESULTS

Improvements in condition-specific HRQOL met the MID threshold. Reductions from baseline in the DDS total score and its four DDS subscales (all P ≤ 0.0013) and in the HFS total score and its two subscales (all P < 0.0001) were observed across all time points. Improvements were observed after both 1 and 2 years for the EQ-5D visual analog scale (both P < 0.0001).

CONCLUSIONS

In CIT-07, 87.5% of the subjects achieved the primary end point of freedom from SHE along with glycemic control (HbA_1c <7% [<53 mmol/mol]) at 1 year post-initial islet transplantation. The same subjects reported consistent, statistically significant, and clinically meaningful improvements in condition-specific HRQOL as well as self-assessments of overall health.

Multiple modality biomarker prediction of cognitive impairment in prospectively followed de novo Parkinson disease

OBJECTIVES

To assess the neurobiological substrate of initial cognitive decline in Parkinson's disease (PD) to inform patient management, clinical trial design, and development of treatments.

METHODS

We longitudinally assessed, up to 3 years, 423 newly diagnosed patients with idiopathic PD, untreated at baseline, from 33 international movement disorder centers. Study outcomes were four determinations of cognitive impairment or decline, and biomarker predictors were baseline dopamine transporter (DAT) single photon emission computed tomography (SPECT) scan, structural magnetic resonance imaging (MRI; volume and thickness), diffusion tensor imaging (mean diffusivity and fractional anisotropy), cerebrospinal fluid (CSF; amyloid beta [Aβ], tau and alpha synuclein), and 11 single nucleotide polymorphisms (SNPs) previously associated with PD cognition. Additionally, longitudinal structural MRI and DAT scan data were included. Univariate analyses were run initially, with false discovery rate = 0.2, to select biomarker variables for inclusion in multivariable longitudinal mixed-effect models.

RESULTS

By year 3, cognitive impairment was diagnosed in 15-38% participants depending on the criteria applied. Biomarkers, some longitudinal, predicting cognitive impairment in multivariable models were: (1) dopamine deficiency (decreased caudate and putamen DAT availability); (2) diffuse, cortical decreased brain volume or thickness (frontal, temporal, parietal, and occipital lobe regions); (3) co-morbid Alzheimer's disease Aβ amyloid pathology (lower CSF Aβ 1-42); and (4) genes (COMT val/val and BDNF val/val genotypes).

CONCLUSIONS

Cognitive impairment in PD increases in frequency 50-200% in the first several years of disease, and is independently predicted by biomarker changes related to nigrostriatal or cortical dopaminergic deficits, global atrophy due to possible widespread effects of neurodegenerative disease, co-morbid Alzheimer's disease plaque pathology, and genetic factors.

Comparative Analyses of the Lipooligosaccharides from Nontypeable Haemophilus influenzae and Haemophilus haemolyticus Show Differences in Sialic Acid and Phosphorylcholine Modifications

Haemophilus haemolyticus and nontypeable Haemophilus influenzae (NTHi) are closely related upper airway commensal bacteria that are difficult to distinguish phenotypically. NTHi causes upper and lower airway tract infections in individuals with compromised airways, while H. haemolyticus rarely causes such infections. The lipooligosaccharide (LOS) is an outer membrane component of both species and plays a role in NTHi pathogenesis. In this study, comparative analyses of the LOS structures and corresponding biosynthesis genes were performed. Mass spectrometric and immunochemical analyses showed that NTHi LOS contained terminal sialic acid more frequently and to a higher extent than H. haemolyticus LOS did. Genomic analyses of 10 strains demonstrated that H. haemolyticus lacked the sialyltransferase genes lic3A and lic3B (9/10) and siaA (10/10), but all strains contained the sialic acid uptake genes siaP and siaT (10/10). However, isothermal titration calorimetry analyses of SiaP from two H. haemolyticus strains showed a 3.4- to 7.3-fold lower affinity for sialic acid compared to that of NTHi SiaP. Additionally, mass spectrometric and immunochemical analyses showed that the LOS from H. haemolyticus contained phosphorylcholine (ChoP) less frequently than the LOS from NTHi strains. These differences observed in the levels of sialic acid and ChoP incorporation in the LOS structures from H. haemolyticus and NTHi may explain some of the differences in their propensities to cause disease.

Diffusion imaging of nigral alterations in early Parkinson's disease with dopaminergic deficits

BACKGROUND

This study reports the baseline characteristics of diffusion tensor imaging data in Parkinson's disease (PD) patients and healthy control subjects from the Parkinson's Progression Markers Initiative. The main goals were to replicate previous findings of abnormal diffusion imaging values from the substantia nigra. in a large multicenter cohort and determine whether nigral diffusion alterations are associated with dopamine deficits.

METHODS

Two hundred twenty subjects (PD = 153; control = 67) from 10 imaging sites were included. All subjects had a full neurological exam, a ((123) I)ioflupane dopamine transporter (DAT) single-photon emission computer tomography scan, and diffusion tensor imaging. Fractional anisotropy as well as radial and axial diffusivity was computed within multiple regions across the substantia nigra.

RESULTS

A repeated-measures analysis of variance found a marginally nonsignificant interaction between regional fractional anisotropy of the substantia nigra and disease status (P = 0.08), conflicting with an earlier study. However, a linear mixed model that included control regions in addition to the nigral regions revealed a significant interaction between regions and disease status (P = 0.002), implying a characteristic distribution of reduced fractional anisotropy across the substantia nigra in PD. Reduced fractional anisotropy in PD was also associated with diminished DAT binding ratios. Both axial and radial diffusivity were also abnormal in PD.

CONCLUSIONS

Although routine nigral measurements of fractional anisotropy are clinically not helpful, the findings in this study suggest that more-sophisticated diffusion imaging protocols should be used when exploring the clinical utility of this imaging modality.

Cognitive performance and neuropsychiatric symptoms in early, untreated Parkinson's disease

This study was undertaken to determine the prevalence and correlates of cognitive impairment (CI) and neuropsychiatric symptoms (NPS) in early, untreated patients with Parkinson's disease (PD).

BACKGROUND

Both CI and NPS are common in PD and impact disease course and quality of life. However, limited knowledge is available about cognitive abilities and NPS.

METHODS

Parkinson's Progression Markers Initiative (PPMI) is a multi-site study of early, untreated PD patients and healthy controls (HCs), the latter with normal cognition. At baseline, participants were assessed with a neuropsychological battery and for symptoms of depression, anxiety, impulse control disorders (ICDs), psychosis, and apathy.

RESULTS

Baseline data of 423 PD patients and 196 HCs yielded no between-group differences in demographic characteristics. Twenty-two percent of PD patients met the PD-recommended screening cutoff for CI on the Montral Cognitive Assessment (MoCA), but only 9% met detailed neuropsychological testing criteria for mild cognitive impairment (MCI)-level impairment. The PD patients were more depressed than HCs (P < 0.001), with twice as many (14% vs. 7%) meeting criteria for clinically significant depressive symptoms. The PD patients also experienced more anxiety (P < 0.001) and apathy (P < 0.001) than HCs. Psychosis was uncommon in PD (3%), and no between-group difference was seen in ICD symptoms (P = 0.51).

CONCLUSIONS

Approximately 10% of PD patients in the early, untreated disease state met traditional criteria of CI, which is a lower frequency compared with previous studies. Multiple dopaminergic-dependent NPS are also more common in these patients compared with the general population, but others associated with dopamine replacement therapy are not or are rare. Future analyses of this cohort will examine biological predictors and the course of CI and NPS. © 2015 International Parkinson and Movement Disorder Society.

Association of hospitalizations for asthma with seasonal and pandemic influenza

BACKGROUND AND OBJECTIVE

Although influenza has been associated with asthma exacerbations, it is not clear the extent to which this association affects health care use in the United States. The first goal of this project was to determine whether, and to what extent, the incidence of asthma hospitalizations is associated with seasonal variation in influenza. Second, we used influenza trends (2000-2008) to help predict asthma admissions during the 2009 H1N1 influenza pandemic.

METHODS

We identified all hospitalizations between 1998 and 2008 in the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project during which a primary diagnosis of asthma was recorded. Separately, we identified all hospitalizations during which a diagnosis of influenza was recorded. We performed time series regression analyses to investigate the association of monthly asthma admissions with influenza incidence. Finally, we applied these time series regression models using 1998-2008 data, to forecast monthly asthma admissions during the 2009 influenza pandemic.

RESULTS

Based on time series regression models, a strong, significant association exists between concurrent influenza activity and incidence of asthma hospitalizations (P-value < 0.0001). Use of influenza data to predict asthma admissions during the 2009 H1N1 pandemic improved the mean squared prediction error by 60.2%.

CONCLUSIONS

Influenza activity in the population is significantly associated with asthma hospitalizations in the United States, and this association can be exploited to more accurately forecast asthma admissions. Our results suggest that improvements in influenza surveillance, prevention and treatment may decrease hospitalizations of asthma patients.

Predicting chronic obstructive pulmonary disease hospitalizations based on concurrent influenza activity

Although influenza has been associated with chronic obstructive pulmonary disease (COPD) exacerbations, it is not clear the extent to which this association affects healthcare use in the United States. The first goal of this project was to determine to what extent the incidence of COPD hospitalizations is associated with seasonal influenza. Second, as a natural experiment, we used influenza activity to help predict COPD admissions during the 2009 H1N1 influenza pandemic. To do this, we identified all hospitalizations between 1998 and 2010 in the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project (HCUP) during which a primary diagnosis of COPD was recorded. Separately, we identified all hospitalizations during which a diagnosis of influenza was recorded. We formulated time series regression models to investigate the association of monthly COPD admissions with influenza incidence. Finally, we applied these models, fit using 1998-2008 data, to forecast monthly COPD admissions during the 2009 pandemic. Based on time series regression models, a strong, significant association exists between concurrent influenza activity and incidence of COPD hospitalizations (p-value < 0.0001). The association is especially strong among older patients requiring mechanical ventilation. Use of influenza data to predict COPD admissions during the 2009 H1N1 pandemic reduced the mean-squared prediction error by 29.9%. We conclude that influenza activity is significantly associated with COPD hospitalizations in the United States and influenza activity can be exploited to more accurately forecast COPD admissions. Our results suggest that improvements in influenza surveillance, prevention, and treatment may decrease hospitalizations of patients diagnosed with COPD.

The precision of human-generated hand-hygiene observations: a comparison of human observation with an automated monitoring system

We compared the observations of nearly 1,400 hand-hygiene-related events recorded by an automated system and by human observers. Observation details differed for 38% of these events. Two likely explanations for these inconsistencies were the distance between the observer and the event and the busyness of the clinic.

Stress-induced skeletal muscle Gadd45a expression reprograms myonuclei and causes muscle atrophy

Diverse stresses including starvation and muscle disuse cause skeletal muscle atrophy. However, the molecular mechanisms of muscle atrophy are complex and not well understood. Here, we demonstrate that growth arrest and DNA damage-inducible 45a protein (Gadd45a) is a critical mediator of muscle atrophy. We identified Gadd45a through an unbiased search for potential downstream mediators of the stress-inducible, pro-atrophy transcription factor ATF4. We show that Gadd45a is required for skeletal muscle atrophy induced by three distinct skeletal muscle stresses: fasting, muscle immobilization, and muscle denervation. Conversely, forced expression of Gadd45a in muscle or cultured myotubes induces atrophy in the absence of upstream stress. We show that muscle-specific ATF4 knock-out mice have a reduced capacity to induce Gadd45a mRNA in response to stress, and as a result, they undergo less atrophy in response to fasting or muscle immobilization. Interestingly, Gadd45a is a myonuclear protein that induces myonuclear remodeling and a comprehensive program for muscle atrophy. Gadd45a represses genes involved in anabolic signaling and energy production, and it induces pro-atrophy genes. As a result, Gadd45a reduces multiple barriers to muscle atrophy (including PGC-1α, Akt activity, and protein synthesis) and stimulates pro-atrophy mechanisms (including autophagy and caspase-mediated proteolysis). These results elucidate a critical stress-induced pathway that reprograms muscle gene expression to cause atrophy.

Neurobehavioural testing in workers occupationally exposed to lead: systematic review and meta-analysis of publications

Although the toxic effects of lead on the central nervous system have been well described, the blood concentration at which lead begins to exert adverse effects remains the focus of debate. A meta-analysis of occupational studies was conducted evaluating the association between neurobehavioural testing results and moderate blood lead concentrations.

CASS Registry long term surgical survival. Coronary Artery Surgery Study

OBJECTIVES

To show the effect of clinical, angio and demographic traits on late survival of Coronary Artery Surgery Study (CASS) patients following coronary artery bypass grafting (CABG) and introduce Hazard Function analysis to CASS survival data.

METHODS

Patients were reached by mail survey with 94% response. By National Death Index, vital status was obtained in 99.7% (n = 8221) with a mean follow up of 15 years. Cox proportional hazard and Blackstone Hazard Function regressions were used to assess effects of preoperative traits.

RESULTS

Ninety percent of patients were alive at 5, 74% at 10 and 56% at 15 years. Of those age 65 and age 75 at operation, 74% and 59% were living at 10 years and 54% and 33% at 15 years (now age 90), survival exceeding the matched U.S. population. Hazard Function falls rapidly after CABG to 9 to 12 months, then rises, doubling by 15 years. Young patients, below age 35, had lower late survival. The time-segmented Cox model (divided at time suggested by the Hazard Function) identified traits showing predictive power early, throughout and late. Female sex, small body surface, ischemic symptoms and emergency status affected survival early. Heavier weight, infarct(s), diuretics, diabetes, smoking, left main and LAD stenosis and use of vein grafts only increased hazard late only.

CONCLUSIONS

There are still lessons from the CASS database. CABG in the elderly is supported by the survival pattern of our patients age 75 at operation. Time-segmented Cox analysis and Hazard Function analysis separate baseline variables into those that predict early mortality and those that predict long survival.

Coronary artery disease in diabetic and nondiabetic patients with lower extremity arterial disease: A report from the Coronary Artery Surgery Study Registry

OBJECTIVE

Patients with lower extremity arterial disease (LEAD) are at an increased risk of having coronary artery disease (CAD). Diabetics are at especially high risk for having LEAD with concomitant CAD. This study was undertaken (1) to define the clinical and arteriographic features associated with CAD among diabetics and nondiabetics with LEAD and (2) to determine the long-term survival and predictors of mortality of diabetics and nondiabetics with LEAD and CAD.

RESEARCH DESIGN AND METHODS

Two hundred sixty-three diabetics and 1137 nondiabetics from the Coronary Artery Surgery Study who had evidence of LEAD, who were 50 years and older, and who had arteriographically proven CAD were monitored for a mean of 12.8 years.

RESULTS

Among all the subjects with LEAD there was a high prevalence of current and past smoking, history of previous myocardial infarction, systemic hypertension, congestive heart failure, high degrees of angina pectoris and unstable angina pectoris, and use of beta-blockers. On arteriographic evaluation a high prevalence of three-vessel epicardial coronary disease and involvement of multiple coronary segments with > or =50% diameter narrowing was found. Multivariate analysis showed the number of coronary segments with >50% occlusion, the presence of cerebrovascular disease, the use of digitalis, and elevated systolic blood pressure were independently associated with diabetes. On follow-up diabetics had a significantly higher mortality rate (mostly cardiac) than nondiabetics: median survival, 8.1 years and 12.7 years, respectively. At 15 years the mortality rates were 77.1% and 62.0%, respectively. On multivariate analysis, age, number of coronary occlusions, number of significantly narrowed epicardial arteries, diminished myocardial contractility, hypertension, and smoking were significant predictors of mortality in the total group and in each subgroup. Coronary artery bypass grafting surgery was protective. The presence of diabetes was an independent risk factor for mortality.

CONCLUSIONS

The presence of LEAD is associated with multivessel epicardial and multiple coronary segment occlusion. On long-term follow-up there is a high mortality rate. In patients with LEAD and diabetes, CAD is especially severe and prognosis is poor.

Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study

BACKGROUND

The influence of prior coronary artery bypass surgery (CABG) versus medical therapy for reducing the risk of postoperative cardiac complications after noncardiac surgery continues to be debated. To further clarify this controversy we studied 24,959 participants in the Coronary Artery Surgery Study (CASS) database with suspected coronary disease by identifying those who required noncardiac surgery during more than 10 years of follow-up.

METHODS AND RESULTS

CASS registry enrollees were either treated with CABG or medical therapy after initial entry. During follow-up, patients who required noncardiac operations were evaluated for hospital death or out-of-hospital death within 30 days of noncardiac surgery and nonfatal postoperative myocardial infarction (MI). At a mean follow-up of 4.1 years, 3368 patients underwent noncardiac surgery, with abdominal (36%), urologic (21%), orthopedic (15%), and vascular being most common. Abdominal, vascular, thoracic, and head and neck surgery each had a combined MI/death rate among patients with nonrevascularized coronary disease >4%. Among 1961 patients undergoing higher-risk surgery, prior CABG was associated with fewer postoperative deaths (1.7% versus 3.3%, P=.03) and MIs (0.8% versus 2.7%, P=.002) compared with medically managed coronary disease. Contrariwise, 1297 patients undergoing urologic, orthopedic, breast, and skin operations had mortality of <1% regardless of prior coronary treatment. Prior CABG was most protective in patients with advanced angina and/or multivessel coronary artery disease.

CONCLUSIONS

In patients with known coronary artery disease, noncardiac surgeries involving the thorax, abdomen, vasculature, and head and neck are associated with the highest cardiac risk, which is reduced among patients with prior CABG.

Coronary artery disease in diabetic patients with lower-extremity arterial disease: disease characteristics and survival. A report from the Coronary Artery Surgery Study (CASS) registry

OBJECTIVE

Patients who have diabetes and lower-extremity arterial disease (LEAD) are at an increased risk of dying from coronary artery disease (CAD). This study was undertaken to: 1) define the clinical and arteriographic factors associated with LEAD among diabetic patients; 2) determine the long-term survival and predictors of mortality of diabetic patients with LEAD, compared to those without LEAD; and 3) determine if the presence of LEAD is an independent risk factor for mortality among diabetic patients with CAD.

RESEARCH DESIGN AND METHODS

A total of 263 diabetic patients from the Coronary Artery Surgery Study (CASS) registry with LEAD, who were > or = 50 years of age, and who had arteriographically proven CAD, were identified and followed for a mean of 12.8 years. A total of 1,349 comparably aged diabetic patients from the CASS registry with CAD and no evidence of LEAD were followed for an equivalent period of time.

RESULTS

Compared with diabetic patients without LEAD, diabetic patients with LEAD were characterized by the presence of cerebrovascular disease, a high rate of current smoking, elevated systolic blood pressure, high grades of angina pectoris, and digitalis use. Severity of epicardial CAD and extent of CAD were not independent predictors of the presence of LEAD. On follow-up, diabetic patients with LEAD had significantly higher mortality (mostly cardiovascular) than diabetic patients without LEAD, with a median survival of 8.1 and 10.9 years, respectively. On multivariate analysis, age, the number of significantly narrowed coronary arteries, and the presence of left ventricular dysfunction predicted mortality in both subsets of diabetic patients. Among all the diabetic patients with CAD, the presence of LEAD was an independent risk factor for mortality.

CONCLUSIONS

Diabetic patients with LEAD have a higher mortality rate (mostly cardiovascular) than diabetic patients without LEAD, despite no apparent anatomic differences in the severity and extent of CAD. This suggests that factors associated with the presence of LEAD, other than the anatomy of the coronary circulation, may play a role in determining survival among diabetic patients with LEAD and CAD.

Effect of hemorrhagic shock and reperfusion on the respiratory quotient in swine

OBJECTIVES

Respiratory quotient, the ratio of CO2 production to oxygen consumption (VO2), is principally affected by the fuel source used for aerobic metabolism. Since the respiratory quotient, VO2, and CO2 production cannot be directly measured easily, indirect calorimetry is commonly used to determine the value of these variables at the airway level (i.e., airway respiratory quotient, airway VO2, and airway CO2 production). However, under nonsteady-state conditions, a variety of phenomena can alter the relationship between true metabolic activity and measurements determined by indirect calorimetry. During exercise, for example, airway respiratory quotient increases as anaerobic threshold is reached because of the disproportionate increase in airway CO2 production that results from the CO2 liberated through the buffering of excess hydrogen ions by bicarbonate. We hypothesized that hemorrhage and reinfusion might change airway respiratory quotient in a consistent manner as shock is produced and reversed.

DESIGN

Prospective laboratory study.

SETTING

University animal laboratory.

SUBJECTS

Eight pigs (25 +/- 2 [SD] kg), anesthetized with fentanyl and relaxed with pancuronium bromide, and mechanically ventilated on room air.

INTERVENTIONS

The animals were sequentially hemorrhaged and then autotransfused while metabolic and hemodynamic measurements were obtained, using continuous indirect calorimetry and continuous applications of the Fick principle. Hemoglobin, arterial lactate concentration, and blood gases for calibration were measured serially. Analysis of variance was used to compare various periods in time.

MEASUREMENTS AND MAIN RESULTS

Between baseline and peak hemorrhage, and between peak hemorrhage and postreinfusion, all of the following variables changed significantly (p < .05): airway VO2 (baseline 6.4 +/- 0.9 mL/min/kg, peak hemorrhage 3.9 +/- 0.6 mL/min/kg, postreinfusion 7.0 +/- 1.4 mL/min/kg); airway CO2 production (baseline 5.5 +/- 0.9 mL/min/kg, peak hemorrhage 4.5 +/- 0.9 mL/min/kg, postreinfusion 6.0 +/- 1.4 mL/min/kg); airway respiratory quotient (baseline 0.87 +/- 0.07, peak hemorrhage 1.16 +/- 0.07, postreinfusion 0.87 +/- 0.05); lactate concentration (baseline 2.4 +/- 1.2 mmol/L, peak hemorrhage 6.7 +/- 1.9 mmol/L, postreinfusion 5.1 +/- 2.0 mmol/L); and delta PCO2 (venous PCO2-PaCO2) (baseline 4.5 +/- 3.6 torr [0.6 +/- 0.5 kPa], peak hemorrhage 12.1 +/- 5.3 torr [1.6 +/- 0.7 kPa], postreinfusion 2.7 +/- 2.7 torr [0.4 +/- 0.4 kPa]).

CONCLUSIONS

Airway respiratory quotient increases in hemorrhagic shock and decreases again as shock is reversed during reinfusion. This phenomenon appears related to the buffering of excess of hydrogen ion during hemorrhagic shock.

Surgical therapy for coronary artery disease among patients with combined coronary artery and peripheral vascular disease

BACKGROUND

Among patients with combined coronary artery and peripheral vascular disease, long-term benefits of surgical therapy compared with medical therapy for coronary artery disease are unknown.

METHODS AND RESULTS

Using prospectively collected data from the Coronary Artery Surgery Study registry, we performed a retrospective cohort analysis of 1834 patients (mean age, 56 years; 20% women) with both coronary artery and peripheral vascular disease and evaluated their long-term outcomes. Of these patients, 986 received (nonrandomly) coronary artery bypass graft surgery, and 848 were treated medically. Perioperative mortality was 4.2% (2.9% in the absence of peripheral vascular disease; P = .02). In a mean follow-up period of 10.4 years, 1100 deaths occurred (80% due to cardiovascular causes). For the surgical group, 4-, 8-, 12-, and 16-year estimated probabilities of survival were 88%, 72%, 55%, and 41%, respectively, and 73%, 57%, 44%, and 34%, respectively, for the medical group (P < .0001). Multivariate analysis demonstrated that type of therapy was independently associated with survival (P = .0001; chi 2 = 15.34). Subgroup analysis suggested that benefits of surgical treatment on survival were limited to patients with three-vessel coronary artery disease and were inversely related to ejection fraction. Survival free of death or myocardial infarction was also significantly better among the surgical group. Type of therapy was significantly associated with occurrence of late events (P = .01; chi 2 = 6.55). Subgroup analysis again demonstrated that beneficial effects of surgery were limited to patients with three-vessel coronary artery disease and were inversely related to ejection fraction.

CONCLUSIONS

Surgical treatment provides long-term benefit for certain subgroups of patients with combined coronary artery and peripheral arterial vascular disease.

Coronary artery disease and coronary artery bypass grafting in diabetic patients aged > or = 65 years (report from the Coronary Artery Surgery Study [CASS] Registry)

A cohort of 317 diabetic patients, aged > or = 65 years, with angiographically proven coronary artery disease, was analyzed and followed for a mean of 12.8 years. Compared with 1,843 age-matched nondiabetic patients, diabetic patients were more likely to (1) have a higher number of coronary occlusions, (2) not be current smokers, (3) have higher systolic but lower diastolic blood pressures, (4) have evidence of peripheral vascular disease, and (5) be women. They did not differ significantly with respect to total cholesterol, family history of coronary artery disease, history of hypertension, or left ventricular hypertrophy. In the total elderly cohort, diabetes was found to be an independent predictor of mortality, conferring a 57.0% increased risk of death. Survival analysis showed that diabetic subjects consistently had higher mortality than nondiabetics. However, the relative survival benefit of coronary artery bypass graft surgery versus medical therapy was comparable in diabetic and nondiabetic patients. Surgical therapy conferred a reduction in mortality of 44%.

Long-term survival in patients with coronary artery disease: importance of peripheral vascular disease. The Coronary Artery Surgery Study (CASS) Investigators

OBJECTIVES

The purpose of this study was to determine the importance of peripheral arterial disease in predicting long-term survival in patients with clinically evident coronary artery disease.

BACKGROUND

Patients in the Coronary Artery Surgery Study (CASS) Registry were followed up for > 10 years.

METHODS

Survival in 2,296 patients with peripheral arterial disease was compared with that of 13,953 patients without peripheral arterial disease using Kaplan-Meier survival curves. All patients had known stable coronary artery disease. Clinical, electrocardiographic (ECG), chest X-ray film and catheterization variables of the two groups were compared using the chi-square statistic or the two-sample t test. The independent effect of peripheral arterial disease (as well as other variables) on mortality was determined utilizing a Cox proportional hazards model.

RESULTS

Patients with peripheral vascular disease were more likely to have hypertension, diabetes, family history of coronary artery disease, previous angina or myocardial infarction, previous coronary bypass surgery or to have smoked. They also had a higher incidence of congestive heart failure, ECG abnormality and modestly increased frequency of three-vessel disease. Independent correlates of long-term mortality for the entire cohort included age, smoking, diabetes, number of diseased coronary vessels, left ventricular function, hypertension, pulmonary disease, anginal class, previous myocardial infarction and peripheral vascular disease (all p < 0.001). At any point in time, patients with peripheral vascular disease had a 25% greater likelihood of mortality than patients without peripheral vascular disease (multivariate chi-square 25.83, hazard ratio 1.25, 95% confidence interval 1.15 to 1.36, p < 0.001).

CONCLUSIONS

Peripheral vascular disease is a strong, independent predictor of long-term mortality in patients with stable coronary artery disease. Aggressive attempts at secondary disease prevention are warranted in this high risk group.

Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff

OBJECTIVES

The Coronary Artery Surgery Study (CASS) required participants to undergo follow-up angiography at 5 years to identify clinical and angiographic features associated with progression of coronary artery disease.

BACKGROUND

The CASS randomized 780 patients at 11 participating clinical centers between an initial strategy of medical therapy versus bypass surgery. Five clinical sites accomplished follow-up angiography in > 50% of their randomized subjects within a 42- to 66-month period after the entry arteriogram (n = 314).

METHODS

Qualified clinical site angiographers, using side by side film review, evaluated an average of 13 segments/patient on both arteriograms for initial stenosis severity, morphologic features, lesion location and occurrence of disease progression or occlusion. Progression was defined as further definite narrowing by > or = 15% and occlusion as lesion progression to > or = 98%. Lesions were subcategorized as to whether they were univariate and had or had not been treated with bypass surgery. Multivariate logistic regression analyses were performed.

RESULTS

For nonbypassed segments, right coronary artery and left anterior descending artery proximal and midlocations were associated with disease progression. For stenosis-containing segments, the initial severity, a non-left anterior descending artery location and increased treadmill duration predicted progression. Segment occlusion was associated with initial lesion severity, right coronary artery location and subsequent interval myocardial infarction. There were few predictors of progression or occlusion in bypassed arteries, other than initial lesion severity.

CONCLUSIONS

Univariate and multivariate associations with lesion progression and occlusion included diabetes, lesion location, elevated cholesterol level, interval infarction and lesion morphology. These angiographic results, collected in a prospective trial, are consistent with known risk factors.

Diagnosis of sternal wound infection by technetium-99m-leukocyte imaging

An imaging study is needed that can detect sternal wound infections and distinguish between superficial and deep sternal wound infection when a clinical diagnosis is uncertain and a decision regarding surgical intervention must be made. We retrospectively reviewed the 99mTc-leukocyte scans of 29 patients referred to rule out sternal wound infection. The presence or absence of deep or superficial sternal wound infection was determined by microbiology and long-term follow-up. Images obtained 4 and 20 hr after injection were reviewed by two nuclear physicians who were blinded to the clinical history. Findings were categorized as normal or abnormal. Abnormal images were further defined as having intense uptake at 4 and 20 hr, increasing uptake between 4 and 20 hr, or other patterns such as focal cold regions, irregular uptake at 4 and 20 hr or increasing uptake between 4 and 20 hr were 100% sensitive and 89% specific for the detection of deep sternal wound infection. The images were also useful for determining the extent of infection. Superficial sternal wound infection could not be reliably detected. The results indicate that 99mTc-leukocyte imaging is useful for the diagnosis of deep sternal wound infection.

Plasma fibronectin levels during cardiopulmonary bypass

Plasma fibronectin, also called cold-insoluble globulin, is a cryoprecipitable glycoprotein with both opsonic and adhesive activities. It binds to collagen, actin, and heparin and can form soluble as well as cryoprecipitable complexes in the cold. Fibronectin augments particulate phagocytosis by the reticuloendothelial system and can influence lung vascular permeability. Plasma fibronectin deficiency is temporally associated with respiratory failure in septic surgical, trauma, and burn patients. We measured plasma fibronectin and albumin levels in nine adults undergoing elective cardiopulmonary bypass to determine whether dilution alone could account for the changes in plasma fibronectin. Plasma fibronectin concentration decreased 17% with the surgical trauma of opening of the chest and placement of the vascular cannulas. On heparinization and initiation of cardiopulmonary bypass, plasma fibronectin fell an additional 48% (P less than 0.001), whereas albumin concentration (corrected for albumin in the pump prime) fell only 25% (P less than 0.001), emphasizing that dilution was not the only mechanism contributing to the decline in plasma fibronectin. Fibronectin levels began to increase after discontinuation of cardiopulmonary bypass and in association with diuresis, but unexpectedly they remained subnormal until 4 days postoperation. Thus the decline in fibronectin concentration with cardiopulmonary bypass may be due to dilution as well as opsonic consumption and possible complexing with heparin in the cold.

Coronary Artery Surgery Study (CASS): comparability of 10 year survival in randomized and randomizable patients

The Coronary Artery Surgery Study (CASS) includes 780 patients with mild or moderate stable angina pectoris or asymptomatic survivors of a myocardial infarction who were randomized to either medical or surgical therapy and 1,319 patients who were eligible for randomization but were not randomized (randomizable patients). There were no substantial aggregate differences observed in any of the survival comparisons after 10 years of follow-up study between the randomized and randomizable patients assigned to the medical (79% versus 80%) or surgical (82% versus 81%) groups or in patient subgroups stratified according to coronary artery disease extent and left ventricular ejection fraction. Cox regression analyses were done with independent variables known to be predictors of survival, including surgical versus medical therapy and randomized versus randomizable group, to test the null hypothesis of a mortality difference between medical versus surgical assignment according to group assignment (randomized versus randomizable). In no case did the initial group category enter as a significant predictor of survival. The results in the randomizable group reinforce those in the randomized group with respect to the medical versus surgical comparison. Two subgroups are identified with a significant surgical advantage: 1) patients with proximal left anterior descending coronary artery stenosis greater than or equal to 70% and an ejection fraction less than 0.50, and 2) patients with three vessel coronary artery disease and an ejection fraction less than 0.50. In both groups, coronary bypass surgery had a statistically significant beneficial effect on survival (p less than 0.05). After a decade of follow-up, the CASS randomizable patients confirm conclusions reached on the basis of the CASS randomized trial.

Alternative conduits for aortocoronary bypass grafting

The internal mammary artery is the premier conduit for initial and repeat coronary artery bypass grafting and should be used as either a pedicled or free graft whenever possible. Saphenous veins from the greater and lesser systems are distinctly second choices but can serve satisfactorily as aortocoronary grafts for many years. When neither the internal mammary arteries nor the saphenous veins are available, the cardiac surgeon today must choose from a wide variety of alternative conduits that have been used periodically over the past two decades for coronary artery bypass grafting.

Predonated autologous blood use in elective cardiac surgery

The risks of homologous blood transfusion are well documented and recently increased with the emergence of acquired immunodeficiency syndrome. Preoperative autologous donation has been suggested to reduce these risks. This is a report concerning 104 consecutive adult autologous donors (group 1) who had an elective cardiac operation. A similar group of 111 patients operated on during the same period but without autologous blood donation was used for comparison (group 2). Both groups contained similar numbers of patients with coronary artery disease, valvular disease, and mixed lesions, and both had several patients with atrial septal defects. Group 2 patients (mean age, 67.8 years) were significantly older than group 1 patients (mean age, 58.9 years) (p less than 0.05). The mean donation in group 1 was 4.1 units, but 12 (11.5%) had to discontinue donations. Increasing angina in 10 (12.2%) of the 82 patients with coronary artery disease was the most common complication, and necessitated hospitalization in two instances. In 77 (75.5%) of the 102 group 1 patients who had operation and 23 (21%) of the 110 group 2 patients, no homologous blood products were required. Group 1 patients used significantly less homologous fresh frozen plasma (0.1 unit versus 0.97 unit; p less than 0.005) and packed red blood cells (0.6 unit versus 2.1 units; p less than 0.001) than group 2 patients. Group 1 patients received 3.3 and 3.1 units of autologous packed cells and plasma, respectively. No complications of autologous transfusion were seen. Predonation of autologous blood is an effective, safe method of reducing homologous blood requirements in elective cardiac operations, but it does carry some risk, especially in patients with coronary artery disease.

Replacement of a degenerated porcine valve within a composite aortic valve graft

A simple technique for replacing a valve prosthesis within a composite aortic root graft is described. This method allows isolated valve replacement without removing the Dacron tube graft or altering the original coronary artery repair.

Risk of noncardiac operation in patients with defined coronary disease: The Coronary Artery Surgery Study (CASS) registry experience

It has been suggested that coronary artery bypass grafting (CABG) is efficacious in patients with severe coronary artery disease before they undergo a major noncardiac operation. The Coronary Artery Surgery Study (CASS) registry population was reviewed to identify variables affecting operative mortality and cardiovascular morbidity for noncardiac procedures, and to assess the influence of prior CABG on these surgical risks. Major noncardiac operations were performed on 1,600 registry patients between June 30, 1978, and June 30, 1981. Operative mortality for individuals without significant coronary artery disease (Group 1) was 0.5% (2/399) and for patients with such disease having CABG prior to a noncardiac procedure (Group 2), it was 0.9% (7/743) (Group 1 versus Group 2, p = 0.42). Patients with significant coronary artery disease undergoing noncardiac operation without prior CABG (Group 3) had an increased operative mortality, 2.4% (11/458) (p = 0.009). Group 2 patients had more severe angina symptoms (p less than 0.001) and more extensive coronary artery disease (p less than 0.001) on entering CASS than Group 3 patients. Postoperative chest pain occurred in 8.7% (40/458) of the Group 3 patients versus 4.5% (18/399) in Group 1 and 5.1% (38/743) in Group 2 (p = 0.004). No group differences were noted for the incidence of perioperative myocardial infarction or arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

Reoperation for coronary artery disease

Repeat coronary artery bypass grafting (CABG) accounts for approximately 5% of all myocardial revascularization procedures in the United States annually; it is estimated that nearly 7000 reoperations will be performed in 1984. Angiographic indications for repeat CABG include primary bypass graft obstruction, progressive coronary arteriosclerosis, and combined graft failure and new coronary artery disease. Saphenous vein obstruction secondary to arteriosclerosis occurs in more than half the bypass grafts at 10 years after CABG. Successful aortocoronary reoperation is dependent on careful attention to special surgical technical considerations such as chest reentry, cardiopulmonary bypass management and myocardial preservation, primary graft handling and identification of the target coronary vessel, choice of available bypass conduits, completeness of revascularization, and hemostasis and blood conservation. Operative mortality for repeat CABG is approximately twice that for an initial aortocoronary bypass procedure. Overall operative morbidity is not significantly different for primary and subsequent myocardial revascularization. Five-year survival after repeat aortocoronary surgery is approximately 90% and compares favorably with survival rates after initial CABG. However, symptomatic relief of angina pectoris is not as effective after a repeat myocardial revascularization as it was after the first CABG; only half the patients are angina-free 5 years after reoperation. As with primary revascularization, long-term graft patency rates after coronary reoperation are superior for the internal artery as compared with the saphenous vein.

Surgical survival in the Coronary Artery Surgery Study (CASS) registry

The overall surgical survival data in the Coronary Artery Surgery Study (CASS) registry have not been published to date, pending the report of the randomized medical-surgical comparison (CASS randomized trial). Non-randomized surgical survival data from the CASS registry are given in this article. The overall medical survival data from the registry were reported previously as a natural history study. There were 8,991 patients in the registry portion of CASS who had primary isolated coronary artery bypass grafting and 8,971 with follow-up of more than 30 days. The 5-year survival for all 8,971 patients was 90%, and the operative mortality was 2.37%. Patients with left main coronary artery disease had an operative mortality of 3.84% and a 5-year survival of 85%, while patients with lesions in other vessels had an operative mortality of 2.12% and a 5-year survival of 91%. Among patients without left main coronary disease, the 5-year survival was 93% in those with single-vessel and 92% in those with double-vessel disease (operative mortality was 1.50% and 1.92%, respectively) and 88% in patients with triple-vessel disease (operative mortality was 2.62%; p = 0.009). When results for patients with left main coronary artery obstruction were compared with those for triple-vessel disease, the 5-year survival figures were 85% and 88%, respectively (p = 0.02) and the operative mortality, 3.84% and 2.62%, respectively (p = 0.03). Patients with normal or nearly normal left ventricular (LV) function (i.e., LV segmental wall motion scores ranging from 5 through 11) had a 5-year survival of 92% and an operative mortality of 1.97%. Patients with moderate impairment (LV score range, 12 through 16) had a 5-year survival of 80% and an operative mortality of 4.21%. In those with poor ventricular function (LV score of 17 or greater), the 5-year survival was 65% and the operative mortality was 6.21%. The difference in survival among the three groups was significant (p less than 0.0001). Of 29 variables used in a stepwise Cox regression analysis, LV wall motion score, congestive heart failure score, age, number of operable vessels, smoking history, LV end-diastolic pressure, and percent of left main coronary artery stenosis were found to have a significant effect on long-term survival (excluding 30-day mortality), and these variables plus surgical priority and height influenced surgical mortality. When height was used in the Cox proportional hazards model, female sex was no longer a significant variable.

Survival following coronary artery bypass grafting in patients with severe angina pectoris (CASS). An observational study

This observational study evaluates the effects of the severity of angina pectoris and the treatment method upon the survival of 4,209 patients in the Coronary Artery Surgery Study registry. In this nonrandomized study, these patients met the criteria used in the Coronary Artery Surgery Study randomized trial, except for the degree of angina pectoris and the method of selection of treatment. The 5 year survival rate was greater than or equal to 93% in patients with Class I and II angina pectoris and normal left ventricular function, regardless of the number of involved vessels or treatment received. Late survival of surgically treated patients with Class III and IV angina pectoris and normal left ventricular function was similar, regardless of the number of vessels involved (greater than or equal to 92% at 5 years). Nonoperatively treated patients with Class III and IV angina pectoris and normal left ventricular function had poorer 5 year survival rates, lowest (74%) in patients with three vessel disease (p less than 0.0001). This difference was also observed in patients with abnormal left ventricular function, three vessel disease, and Class III and IV angina pectoris; the 5 year survival rates were 82% for the operative group and 52% for the nonoperative group (p less than 0.0001). These data confirm the importance of clinical as well as anatomic factors in determining the prognosis of patients with ischemic heart disease and indicate that coronary artery bypass grafting can improve late survival in patients with triple vessel disease and severe angina pectoris.

Comparison of operative mortality and morbidity for initial and repeat coronary artery bypass grafting: The Coronary Artery Surgery Study (CASS) registry experience

The National Heart, Lung, and Blood Institute's Coronary Artery Surgery Study (CASS) registry population was reviewed to allow comparison of operative mortality and morbidity rates for initial and repeat coronary artery bypass grafting (CABG) procedures. Standardized data collection was employed in CASS during patient entry (July 1, 1974, to May 31, 1979) and follow-up (ended November 30, 1982). Initial CABG was performed on 9,369 patients. Mean follow-up was 60.5 months. Repeat CABG was required in 283 patients (3.0%). The mean interval between operations was 39.3 months. Individuals needing reoperation tended to be young (p less than 0.0001) and female (p less than 0.002) and to have less extensive coronary artery disease (p less than or equal to 0.0001), less left ventricular impairment (p less than 0.0001), less evidence of congestive heart failure (p = 0.006), and fewer coronary vessel systems bypassed at the first operation (p less than 0.0001). Repeat CABG carried an increased risk of death compared with initial CABG (5.3% versus 3.1%, respectively; p less than 0.05). However, the rates of perioperative myocardial infarction (6.4% for repeat and 5.8% for initial CABG) and of all surgical complications combined (30.6% versus 27.9%) were not significantly different from those at initial CABG.

Reoperation for aortic coarctation

Reoperation for aortic coarctation has become common because of several factors: (1) increased physician awareness that hypertensive cardiovascular disease continues to threaten the prognosis of the patient following coarctectomy and that investigation in some symptomatic individuals after coarctectomy will demonstrate a residual or recurrent coarctation, even many years after the primary repair; (2) the widespread application of stress testing, which can reveal marked arm-to-leg pressure gradients not observed at rest, to the routine postcoarctectomy follow-up examination; (3) improved noninvasive aortic evaluation techniques, such as ultrasound; and (4) higher salvage rates among infants undergoing urgent coarctation repairs and the recognition that these children subsequently are at high risk for recoarctation. A surgical decision-making process characterized by flexibility provides maximum patient safety; no single reoperation technique can be applied in all situations. Individual circumstances may dictate recoarctation repair by resection with end-to-end anastomosis, tube graft interposition, aortoplasty, or tube graft bypass. The need for a temporary aortic shunt or partial left atriofemoral bypass to maintain adequate distal aortic perfusion pressure during the repair means that these methods must be available at all reoperations. Diligent efforts to repair all hemodynamically significant residual and recurrent coarctations are necessary if the natural fate of premature death is to be avoided for patients with these lesions.

Potential for percutaneous transluminal coronary angioplasty before initial and repeat coronary artery bypass grafting in the Coronary Artery Surgery Study (CASS) Registry population

Retrospective analysis of preoperative angiograms was conducted to determine potential candidacy for PTCA among the NHLBI Coronary Artery Surgery Study (CASS) Registry population undergoing initial and repeat CABG. Conservative criteria believed to be universally acceptable for PTCA were used. Patients were considered potential PTCA candidates if: (1) CABG had been performed to only 1 coronary artery system; (2) the critical disease was localized to the most proximal segment of that coronary artery system; (3) all distal segments of that coronary artery system were free of critical disease; and (4) the morphologic characteristics of the obstructing lesion were discrete and isolated. Left main CAD was excluded. Among persons who underwent initial CABG, 2.8% (261 of 9,369) were PTCA candidates, and 7.1% (20 of 283) of those who underwent repeat CABG were considered suitable for PTCA. The operative mortality risk of the PTCA candidates who underwent initial CABG was 0.4% (1 of 261). No PTCA candidates died during repeat CABG. Perioperative MI occurred in 2.3% (6 of 261) of the PTCA candidates who had initial CABG; none occurred among those who underwent repeat surgery. Total surgical complications occurred in 15.7% (41 of 261) of the PTCA candidates at initial CABG and in 5% (1 of 20) who had repeat CABG. These operative mortality and morbidity risks are lower than those reported for similar patients who undergo PTCA.

Cardiac rhabdomyoma in the neonate: surgical management

Rhabdomyoma is the most common cardiac neoplasm in neonates. Tuberous sclerosis is found in half of the patients with rhabdomyomas. We maintain a surgical policy of accepting for operation only neonates in whom it has been demonstrated that the primary cause for hemodynamic compromise is obstructing, intracavitary neoplasms. Only the intracavitary portions of the rhabdomyoma are excised; no effort is made to completely remove all intramural tumors. Rhabdomyomas demonstrate benign pathological characteristics and may regress. Neonates with rhabdomyomas but no hemodynamic impairment, or those in whom only intramural masses can be demonstrated, are not considered surgical candidates. Tuberous sclerosis by itself should not be judged a contraindication to operation. The results of our surgical policy regarding rhabdomyomas in neonates are reported in two case presentations.

Preservation of the myocardium during coronary artery bypass grafting

The influence of three methods of myocardial preservation used during coronary artery bypass grafting on operative mortality and perioperative myocardial infarction was evaluated in seven institutions participating in the Coronary Artery Surgery Study (CASS). Both operative mortality and perioperative infarctions were comparable with either normothermic and topical hypothermic myocardial preservation. The addition of potassium cardioplegia to hypothermia lowered both operative mortality and perioperative myocardial infarction (p less than 0.01 and p less than 0.001, respectively). Stepwise multivariate discriminant analysis revealed that the high-risk clinical and angiographic variables were the most important determinants of operative mortality, followed by surgical priority and the use of potassium cardioplegia. However, none of the clinical, angiographic and surgical variables other than the use of potassium cardioplegia influenced the incidence of perioperative myocardial infarction.

Anomalous right subclavian artery arising proximal to a postductal thoracic aortic coarctation

Approximately 1% of patients with postductal thoracic aortic coarctation have an associated anomalous right subclavian artery. Previous reports indicated that the aberrant right subclavian vessel arose distal to the coarctation site. The case of a patient is presented in whom the anomalous right subclavian artery originated proximal to the postductal coarctation. We believe this to be among the first reports of this entity. The embryological development pathway and clinical implications of this congenital defect complex are discussed.