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Objectives: Coronary artery bypass grafting carried out in patients in cardiogenic shock or receiving cardiopulmonary resuscitation is an infrequently performed procedure, disrupting the normal process with a dramatic early risk. These circumstances mandate an analysis of the benefit, including the early identification of the late survivors., Methods: A consecutive series of patients undergoing coronary artery bypass grafting while in cardiogenic shock (n = 167) or while receiving cardiopulmonary resuscitation (n = 92) from August 1979 until August 2001 were studied by using time-related and multivariate methodologies and a common-closing-date follow-up methodology. The events leading to the preoperative condition were either a recent catheterization, recent coronary artery bypass grafting, recent percutaneous transluminal coronary angioplasty, an infarction at home, an infarction in the hospital, or an infarction after a recent infarction., Results: The 1- and 10-year survival was 59% +/- 6% and 47% +/- 7%, respectively. A normal hazard of late death was observed beyond the protracted early hazard. Multivariate analysis of survival identified an increased risk in the presence of additional comorbidity, treated diabetes, a lower pH at entry into the operating theater, and the presence of triple-vessel disease. The discriminatory power for hospital mortality of the predictive variables was low (receiving operator characteristic range, 0.56-0.69). The 30-day freedom from hospital discharge alive was 33% +/- 7%. The 8-day freedom from stroke was 94% +/- 3%, and 8-day freedom from mechanical univentricular or biventricular support was 87% +/- 5%. The 10-year freedom from cardiosurgical reintervention was 90% +/- 6%., Conclusions: Coronary artery bypass grafting in cardiogenic shock or during cardiopulmonary resuscitation has an extremely high and protracted periprocedural risk but is balanced by a satisfactory late survival. An early prediction of the hospital survivors is difficult.

This multi-centre, parallel group, randomized, double-blind study compared the efficacy and safety of high-dose remifentanil administered by continuous infusion with an intermittent bolus fentanyl regimen, when given in combination with propofol for general anaesthesia in 321 patients undergoing elective coronary artery bypass graft surgery. A significantly lower proportion of the patients who received remifentanil had responses to maximal sternal spread (the primary efficacy endpoint) compared with those who received fentanyl (11% vs 52%; P<0.001). More patients who received remifentanil responded to tracheal intubation compared with those who received fentanyl (24% vs 9%; P<0.001). However, fewer patients who received remifentanil responded to sternal skin incision (11% vs 36%; P<0.001) and sternotomy (14% vs 60%; P <0.001). Median time to extubation was longer in the subjects who received remifentanil than for those who received fentanyl (5.1 vs 4.2 h; P=0.006). There were no statistically significant differences between the two groups in the times for transfer from intensive care unit or hospital discharge but time to extubation was significantly longer in the remifentanil group. Overall, the incidence of adverse events was similar but greater in the remifentanil group with respect to shivering (P<0.049) and hypertension (P<0.001). Significantly more drug-related adverse events were reported in the remifentanil group (P=0.016). There were no drug-related adverse cardiac outcomes and no deaths from cardiac causes before hospital discharge in either treatment group.

Eighteen patients suffering from acute left heart failure were selected as candidates for Hemopump support. In 6 patients, peripheral atheromatosis prevented insertion of the device. Of the remaining 12 patients, 9 had postcardiotomy shock, 2 had acute rejection after orthotopic heart transplantation, and 1 had acute myocardial infarction complicated by a large postinfarction ventricular septal defect. During Hemopump support, hemodynamics recovered in all patients. Major complications were related to mechanical pump failure, such as fracture of the drive cable and expulsion of the cannula out of the ventricle, or to hemolysis of variable degree. Seven patients (58%) survived and were discharged from the hospital: the 2 patients bridged to heart transplantation and 5 of the 9 postcardiotomy patients, including 1 who could not be weaned but later underwent successful transplantation. The patient with the postinfarction ventricular septal defect died after removal of the device because of hemolysis. These results indicate that the Hemopump is a relatively noninvasive and efficacious left ventricular system of moderate power.

The cardioprotective effects of lidoflazine, a calcium entry blocker, were tested in patients undergoing multiple aorta-coronary bypass grafting (at least four grafts). Intermittent aortic cross-clamping at 25 degrees to 28 degrees C was used. Mean cross-clamp time was 11 minutes for one distal anastomosis. Patients were randomized into three groups: a control group (I), a group (II) pretreated with 0.5 mg . kg-1 lidoflazine intravenously before cardiopulmonary bypass (CPB), and a group (III) pretreated with 1 mg . kg-1 lidoflazine intravenously. The following markers of ischemia are used: (1) adenosine triphosphate (ATP), creatine phosphate (CP) and glycogen determined in transmural left ventricular biopsy specimens taken at the beginning and end of CPB; (2) ultrastructure in a similar pair of specimens; and (3) hemodynamic recovery 15 minutes after cessation of CPB. At the end of the intervention, ATP decreased to 73% in Group I but remained unchanged in Groups II (98%) and III (88%). CP decreased to 82% in Group I and remained unaltered in Groups II (100%) and III (110%). Glycogen decreased in Group I (to 44%) and in Group II (78%) but remained unchanged in Group II (138%). Ultrastructural study showed better preservation of the glycocalyx and sarcolemma in Group III than in Group I. Left ventricular stroke work index remained unaltered after CPB in Group III but decreased in Groups I and II to about 60% of its initial value. Thus lidoflazine pretreatment protects the myocardium in a dose-dependent manner against deterioration of myocardial function and structure.