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Retrograde cardioplegia is still debated due to heterogeneous left ventricular flow distribution. The purpose of this study was to compare retrograde flow distribution delivered through the coronary sinus with two patterns of cannula. Fifty four patients were prospectively randomized to receive cold crystalloid retrograde coronary sinus cardioplegia with lither a manual inflating balloon cannula (group I, 24 patients) or a self-inflating balloon cannula (group II, 30 patients). Left ventricular distribution of the cardioplegic solution was assessed by monitoring the left ventricular wall temperatures (anterior and posterior). The cardioplegic retrograde infusion was stopped as the anterior wall temperature reached 12 degrees C. In group II, 70.8% of patients had an identical cooling in the anterior and posterior wall of the left ventricle, versus 40.9% in group I (p < 0.05). The mean temperature difference between anterior and posterior wall was 2.9 degrees C (standard deviation: 2.9 degrees C) in group II versus 5.7 degrees C (standard deviation: 4.3 degrees C) for group I (< 0.05). The retroplegia cannula with the self-inflating balloon allows a better distribution of the cardioplegia flow than the manually inflating balloon. We think that this is due to the shape of the self-inflating balloon which more closely fits the morphology of the coronary sinus.

A technique of coronary surgical angioplasty is described. The long arteriotomy of the coronary artery over the stenosis is closed with the Internal Thoracic Artery (ITA) giving an enlargement patch effect. The majority of the atheromatous plaque is excluded from the lumen of the anastomosis and placed outside the suture line. The origin of the collateral arteries is preserved in the vascular lumen. The remodeled coronary artery is composed of a small gutter of native coronary artery and the whole surface of the ITA wall. In some cases, it is useful to associate a limited endarterectomy with the angioplasty. 66 surgical angioplasties have been performed in extensive coronary disease. Operative mortality was 5.4% with a myocardial infarction rate of 5.4%.

The marked decrease in neuropsychiatric morbidity (NPM) following coronary artery bypass (CAB) over a period of four years led us to carry out a retrospective study in order to identify the cause. Two hundred fifty-eight consecutive CAB procedures were performed between 1983 and 1986. For 133 patients (group A), the CAB procedure was performed with left ventricular vent (LVV) and for 125 patients (group B) without LVV. In group A, 93 patients (group A1) had cardiopulmonary bypass (CPB) with a bubble oxygenator and 40 patients (group A2) had CPB with a membrane oxygenator. In group B, 30 patients (group B1) had CPB with a membrane oxygenator without filter in the arterial line and 95 patients (group B2) had CPB with a membrane oxygenator and filter in the arterial line. The reduction in NPM arose from the removal of the LVV, as the incidence of NMP was in group A 24.6% versus 12.3% in group B (p < 0.05). The substitution of the bubble oxygenator by a membrane oxygenator does not alter the incidence of NPM: 23.3% in group A1 versus 27.5% in group A2 (p > 0.05) nor did incorporation of a filter in the arterial line: 10% in group B1 versus 13.1% in group B2 (p > 0.05). Introduction of air in the left ventricle via an LVV catheter opening and coronary arteriotomy therefore causes gaseous microembolic events responsible for NPM following CAB.

From 1985 to november 1989, 270 patients underwent sequential anastomosis with left internal mammary artery (LIMA) on left descending artery (LDA) and diagnonal artery (DA). The first 120 cases have 100% one year follow-up. The perioperative status was: angina stage III or IV: 59%; myocardial infarction (MI): 45%, stenosis of 3 vessels: 52.5%; stenosis of main coronary artery: 10.8%. 2.25 anastomoses were performed per patient. Side-to-side anastomosis (kissing) were not diamond anastomoses but axial and longitudinal. The use of fibrin gllude provides regular curves of the graft between anastomosis. Mortality was 0.8%, morbidity was: MI: 4.2% (2 small infarcts in anterior vessels, 3 others in non-grafted vessels); mediastinitis: 1%; severe bleeding (reoperation): 1%. At one year 93% of patients are free from angina and 71 patients underwent angiographic assessment (145 LIMA anastomosis). Results are as follow: side-to-side anastomosis patency: 98.5%; distal anastomosis obliteration: 3%; LDA anastomosis patency: 95.7% overall sequential anastomosis patency: 97.6%. These results have led our cardiologist in Brest to naturally prefer a surgical approach than percutaneous angioplasty when LDA and DA are involved.

Distal latero-circumflex arteries (DLCA) and posterior descending artery (PDA) are anatomically too far and cannot be revascularized with internal mammary artery (IMA) by a conventional procedure. The reimplantation of the right IMA into the left IMA in situ increases (2 times) the length of right IMA graft available. Fifty-five patients underwent this technique. Their preoperative status was: 22 males, 3 females; mean age: 57 years, 38% myocardial infarction (MI). Coronary angiography showed: stenosis of the left main coronary artery: 3; stenosis of 3 vessels: 15; 2 vessels: 10; 2.3 anastomoses by patient were performed with Y right and left IMA procedure: 24 LDA, 8 diagonals, 25 DLCA and 1 PDA anastomosis. No deaths were observed in this short series. Morbidity was: 1 MI, 2 sternal sepsis, 1 bilateral phrenic paralysis (all were cured without sequelae). To date (March 90) 15 patients have been followed for 3 to 12 months, 12 are angina-free, 3 are significantly improved, 11 have a negative exercise test. Thallium test is normal in the revascularized area in 14 patients. Seven angiographies have been performed (6 months to 1 year) and all Y right IMA are patent.

The authors report a case of internal mammary artery graft anastomosed to the left anterior descending coronary artery (LADC) which was found to be non functional in the early post-operative period (one month) but second catheterization at one year revealed the graft to be patent with thrombosis of the LADC. This case shows the flow adjustment possibilities of internal mammary artery graft.

In this series of 184 patients (pts), 312 internal mammary arteries were used to graft 430 coronary arteries. Two mammary arteries were used in 104 pts and sequential anastomoses were performed in 118 pts. The operative mortality was 1.6% and the peri-operative myocardial infarction was 4.1%. 9% of patients had post-operative complications: 1% of bilateral phrenic paralysis, 2.1% of post-operative hemorrhage leading to reoperation, 1.6% of sternal infection, 0.5% of true mediastinal infection, 1.6% of sternal dehiscence and 2.7% of reversible psychiatric illness. A 3 month follow-up was available in 160 pts. 95% of patients became angina free, the thallium scan shown a normal uptake of thallium at maximal stress in the myocardial grafted area in 92% of the patients.