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Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

During the past 12 years, 13 patients with atrial (10 left and 3 right) myxoma have been treated. The tumors of the left atrium produced signs and symptoms of mitral valve obstruction and/or subacute bacterial endocarditis and those of the right atrium manifestations of tricuspid valve disease or of pulmonary embolus or hypertension. The diagnosis was established by angiocardiography in 8 patients, at surgery performed for suspected mitral stenosis in 3 patients, and at autopsy in 2 patients. Resection of the atrial myxoma alone in 5 patients or with atrial septum where the atrial myxoma was attached in 4 or with the whole right atrial wall where the atrial myxoma was attached in one patient was performed and all are doing well without evidence of recurrence. Studies of experimentally produced 1.5-3 cm in diameter left atrial thrombus in 30 dogs divided into 5 groups and followed cineangiocardiographically and sacrificed from 14 days to 6 months indicated that the implanted thrombus is absorbed over a 3 to 6 month period. These experimental and human left atrial thrombi were found to be histologically and histochemically different from human atrial myxomas. The electron microscopic studies performed on some of the resected atrial myxomas suggested that the atrial myxoma cells are active cells of endotheilial origin. These observations suggest that atrial myxoma is a primary tumor of the heart which can mimic other clinical entities, and the results of its surgical treatment are gratifying and long lasting.

Spontaneous rupture of the esophagus remains a medical and surgical challenge. Its diagnosis is often missed or delayed resulting in increased morbidity and mortality, and controversy exists as to the mode of therapy for the cases seen later than 12 hours after rupture. During the last seven years, nine patients were treated at Grady Memorial Hospital. Four patients, “early group,” were operated upon within 12 hours from the onset of their symptoms and five, “late group,” were operated upon between 20-76 hours (average 41) after rupture. All four patients in the “early group” had primary repair of the rupture and two had, in addition, fundoplication. From the two patients with primary repair alone, one developed postoperative leakage at the esophageal suture line, which closed spontaneously; whereas, in the two patients with fundoplication, no leakage occurred. Three of the four patients recovered and one died from renal failure, gastrointestinal bleeding, and gastric perforation. In the “late group” one patient had T-tube drainage of the esophagus and died. Two had primary repair alone with one death and the other two had primary repair with fundoplication 20 and 76 hours postrupture and both recovered. The two deaths in the “late group” were due to leakage at the site of the rupture. This study suggests that even in patients diagnosed late as having rupture of the esophagus, primary repair can be implemented with reasonable success. Good mediastinal, pleural and gastric drainage, high levels of appropriate antibiotics, and provision of good nourishment are of paramount importance for the successful management of these desperately ill patients.

Twenty-six consecutive patients underwent combined aortic valve replacement and myocardial revascularization at the Emory University Affiliated Hospitals between May, 1973 and March, 1976. Acute myocardial infarction resulted in two operative deaths (8%). There have been four late deaths, all Class IV preoperative. The age range was 37 to 79 years with an average age of 60. Preoperatively all patients were Class IV or late Class III. Twenty-three patients had symptoms of angina pectoris; congestive heart failure was evident in 56%. Postoperatively, 70% are now Class 1 or II. Single coronary bypass was performed in 16 patients, double in 6, and triple in three. Double bypass plus mitral valve replacement was required in two with aneurysmectomy in one. The rate of intraoperative infarction was 27% for the series but only 7% in the last year. The methods of intraoperative myocardial preservation and the technical approach for the operative procedures were variable. Results with each method are correlated, and currently preferred techniques are presented and discussed. Best results were obtained in patients who presented early in their symptomatic course with isolated proximal coronary lesions and good renoff vessels. Excellent results could be achieved despite advanced age of patients, requirement for multiple bypass grafts, and correction of other associated cardiac lesions. Poorest results were obtained when long-standing ventricular failure was combined with poor vessels distal to coronary stenoses.

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease (CAD), thus possibly redefining candidates for coronary bypass surgery (CABS). Between October 1980 and June 1982, 777 patients having PTCA and 2068 patients having CABS were analyzed for differences in clinical presentation, complications, and early outcome. Patients having CABS were significantly older, had a higher incidence of hypertension (46% vs. 32%), more multivessel disease (80% vs. 12%), and poorer left ventricular function (nl. wall motion = 88% vs. 52%). The incidence of myocardial infarction in patients after PTCA was 1.0% (8/777). Emergency CAB was required in 5.3% of patients following PTCA. There were no deaths following the angioplasty procedure and 25 deaths in 2068 patients having CABS (hospital mortality rate = 1.2%). Since 1973, there has been a progressive decline in hospital mortality rate (now, less than 1%), postoperative infarction (now, 3%), requirement for inotropic drugs (now, 5%) and frequency of IABP (less than 1%). Increasing ability to achieve complete revascularization now means improved survival and freedom from angina with CAB surgery. PTCA and CAB are both procedures that may be used effectively for selected patients, depending on clinical presentation, extent of CAD, and left ventricular function (LVF). Careful patient selection affords the opportunity for use of PTCA in patients with single-vessel disease (SVD) and good LVF and CABS in patients with multivessel disease, regardless of LVF. Symptomatic patients with SVD and total vessel occlusion are not candidates for PTCA. Our data demonstrate that both PTCA and CABS may be accomplished with very low perioperative complications and hospital mortality.

Clinical data on 3,479 consecutive patients having coronary bypass surgery were retrospectively analyzed. Perioperative complications, incomplete revascularization, and reduced long-term survival could frequently be correlated with manifestations of myocardial damage. Patients with triple vessel and left main coronary disease had a greater frequency of inotropic requirements than did patients with single or double vessel disease (7.9% and 8.6% vs. 3.8% and 4.2%). Inotropic requirements in the perioperative period were significantly increased for patients with preoperative left ventricular dysfunction; a history of heart failure or multiple infarctions did not significantly increase the incidence of inotropic requirements. Presence of previous myocardial infarction, heart failure, or left ventricular contraction abnormalities significantly decreased the ability to achieve complete revascularization with bypass grafting. Hospital mortality since 1976 has been 0.8% (25/3,040). Hospital mortality was significantly increased by history of myocardial infarction, hypertension, heart failure, extent of anatomic disease, presence of preoperative ST-T wave changes, and severe abnormalities of left ventricular function. Hospital mortality in patients with ejection fraction ≤0.35 was 3.4% vs. 1.3% for those >0.35. Anginal pattern, history of hypertension, previous myocardial infarction, preoperative heart failure all significantly affected long-term survival. Occurrence of perioperative myocardial infarction did not adversely influence long-term survival. Patients with normal left ventricular function had excellent 42 month survival regardless of vessel disease (95%, 96%, and 94% for single, double, and triple vessel disease, respectively). Survival was significantly less for such patients with abnormal left ventricular function. Inability to achieve complete revascularization did not adversely affect hospital mortality, but did significantly reduce late survival. The important effect which complete revascularization had on long-term survival appeared to increase with increasing severity of coronary disease. Although bypass grafting improves survival in patients with multivessel disease and left ventricular dysfunction, the benefits appear to be significantly reduced once manifestations of left ventricular damage have occurred.

Patients having coronary bypass and aneurysm resection (N = 40) or aneurysm plication (N = 32) were compared with patients having coronary bypass without aneurysm (N = 2782). Unlike other series, the primary indication for surgery in the aneurysm patients was angina pectoris, with heart failure playing a secondary role. Multivessel disease was present in 83% of the patients with aneurysm. Total occlusion of the anterior descending coronary artery was more prevalent in the group of patients who had aneurysmectomy (75%) than in rhe group of patients who had plication (38%), and more grafts/patient could be performed in the plication group (2.6 vs 2.0). Location of the aneurysm was most often anteroapical (N = 55) and infrequently inferior (N = 6). Septal wall motion was akinetic or aneurysmal in 47% of the aneurysmectomy group, and 10% of the plication group. Postoperative requirements for inotropes or intra-aortic balloon assist was much higher in the aneurysm group (aneurysmectomy or plication) than in patients without aneurysm having bypass. Hospital mortality for aneurysm patients was 2.7% versus 1.4% in patients without aneurysms having coronary bypass. The actuarial survival rate at 42 months for all aneurysm patients was 90%. Improvement in anginal symptoms after plication and coronary bypass (96%) was more frequent than with aneurysmectomy and coronary bypass (76%) and this was attributed to larger viable muscle mass and greater revascularization. Although two-thirds of patients having surgery for aneurysms had improvement in heart failure symptoms after operation, 30% of those having aneurysmectomies and 35% of those having plications said they were unimproved after surgery. However, this could be explained by the finding that a significant number (35% of the aneurysmectomy and 45% of the plication group) were in heart failure Class I prior to operation. Hospital mortality has been progressively reduced and late survival increased by the surgical treatment of left ventricular aneurysm, primarily through early operation at a time when coronary bypass can be used as an adjunct to aneurysm resection or plication.

The clinical course of 22 patients with acute endocarditis treated surgically less than six weeks after the onset of antibiotic therapy was reviewed. The aortic valve was infected in 13 patients, the mitral in six, the tricuspid in two, and one patient had both aortic and mitral valve involvement. The indications for surgical intervention before the completion of adequate antibacterial therapy included uncontrollable congestive heart failure, persistent sepsis, systemic embolization, and multiple septic pulmonary embolizations. The annulus was involved by the infectious process in five of the 13 patients with aortic valve endocarditis, in one of the two patients with tricuspid valve infection, and in none of the patients with mitral valve endocarditis. There were two surgical deaths, for a mortality of 9.1%. During the follow-up period, four patients died three months, seven months, four years, and seven years after surgery. The remaining patients have been followed up for a period of five months to 10 years. One patient has a hemodynamically insignificant paravalvular leak, and another developed paravalvular regurgitation and a false aneurysm of the left sinus of Valsalva two weeks after the initial operation. She subsequently underwent successful valve replacement and repair of the aneurysm. This study confirms that valvular replacement should be done for acute endocarditis as soon as indicated, and that the incidence of reinfection and/or the development of valvular or paravalvular problems is small even in the patients with incomplete antimicrobial therapy, whether or not the annulus is involved by the infectious process.

Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.

One hundred and fifty-two patients age 70 years or more underwent aortic valve replacement (AVR) at Emory University Hospital between July 1, 1974 and July 1, 1982. Of these, 98 had isolated AVR (elderly AVR group) and 54 had concomitant coronary artery bypass grafts (elderly AVR/CABG group). Results of surgery in these patients were compared to results in patients aged 20 to 69 years operated on in the same period (young AVR/CABG groups). Comparative descriptors with statistically significant differences included a higher incidence of both stable and unstable angina in patients undergoing concomitant CABGs ; less cardiomegaly in the young AVR/CABG group; less hypertension, a higher incidence of pure aortic regurgitation, and less frequent use of inotropes in the young AVR group; a higher perioperative stroke rate in elderly AVR/CABG patients; a higher perioperative psychosis rate in patients having CABGs regardless of age; and a longer postoperative hospital stay for the elderly patients. There were no significant differences between the four groups for the following descriptors: sex ratio; history of congestive heart failure; the presence of atrial fibrillation; left ventricular end diastolic pressure, ejection fraction and contractility; number of diseased coronary arteries; number of vessels bypassed; use of the intra-aortic balloon pump; re-exploration for hemorrhage; perioperative myocardial infarction rate; and major wound infection rate. Operative mortality was 5.1% for the elderly AVR group, 5.6% for the elderly AVR/CABG group, 1.9% for the young AVR group, and 5.1% for the young AVR/CABG group (p = NS). Overall, hospital mortality was 3.3%. Actuarial survival curves for all elderly versus all young patients showed no significant difference. The curve for elderly patients compares favorably with the actuarial survival of the same age group in the general population. Actuarial survival curves for the four subgroups did not differ significantly when compared at a follow-up of 36 months after surgery. We conclude that AVR with or without concomitant CABGs can be performed in elderly patients with an acceptably low mortality and morbidity, and the postoperative survival compared favorably both with younger patients and with the general population of the same age.