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Mesenteric ischemia after cardiac surgery is rare but dramatic. We present a patient who had acute mesenteric ischemia following low cardiac output after coronary artery bypass grafting. Our patient was successfully treated with continuous intra-arterial perfusion with papaverine. We think that selective angiography must be performed as early as mesenteric ischemia is suspected, to get earlier diagnosis and treatment of an ischemic patient.

Out of 2 638 patients undergoing coronary bypass surgery at the Arnault Tzanck Centre from 1973 to September 1984, 305 (12%) also required coronary endarterectomy. One hundred and eleven of these patients had control angiographies at the Centre and were the object of this study. Endarterectomy was carried out on a totally occluded artery in 38% of cases and was performed out of necessity in the other cases. One hundred and twenty-nine disobliterations were performed in these 111 patients. The average number of bypass grafts per patient was 2.8. The overall hospital mortality was 6% (19 out of 305) which was higher than for bypass surgery alone. The postoperative myocardial infarction rate was 10%. The 117 control angiographies were performed on average during the 8th month after surgery; these controls were routine in 99 cases (84.5%) in Stage I of the NYHA classification and for recurrent angina in 18 cases (15.5%). The endarterectomised vessel was patent in 72% of cases, which was less than the patency rate of the bypass grafts. Considering the indications of necessity, this result is satisfactory and is compared which those of other reported series.

The introduction of intracoronary thrombolysis as a treatment for myocardial infarction has led to an increase in the number of very early coronary angiographies carried out in the acute phase of myocardial infarction. These investigations can be performed without excessive risk. In some cases, severe stenosis with significant distal circulatory impairment without evidence of thrombosis is found. In these very early investigations, these findings may represent a "pre-thrombolic" lesion in an evolving myocardial infarction. Six cases of very severe pre-thrombolitic stenosis of the LAD were observed in a series of 67 coronary angiographies performed in the early stages of myocardial infarction. These six cases were selected on strict clinical, ECG and angiographic criteria. One patient was hospitalised with cardiogenic shock. The six patients underwent emergency coronary bypass surgery: average time from admission to coronary angiography was 55 minutes; average time from coronary angiography to surgery was 3 hours. These 6 pre-thrombolic lesions of the LAD were also associated with lesions of the left circumflex and right coronary arteries. There were no operative complications but two patients had stormy immediate postoperative periods. There was no hospital mortality. All patients were reinvestigated at 1 month and all grafts were shown to be patent. The left ventricular ejection fractions improved in 3 cases, remained unchanged in 2 cases, and deteriorated in 1 case (the patient with cardiogenic shock). These results suggest that emergency coronary bypass surgery is a rational treatment of pre-thrombolic coronary stenosis observed at early coronary angiography in patients with evolving myocardial infarction in order to preserve as much myocardial muscle as possible.

The authors report on an experiment with 17 cases, in which valvular substitution and bypass were combined. This type of operation carries a greater operative risk than that of separate operations, but a complete surgical correction can be obtained. The mortality rate diminishes with the improvement of the surgical team's experience.

Coronary bypass was carried out in four patients who have received an intracoronary streptokinase infusion for acute myocardial infarction. Indications for emergency operation were a myocardial ischaemia time of less than 4 h and a slow flow in the reopened artery despite percutaneous transluminal coronary angioplasty. Two patients were in cardiogenic shock treated by inotropic drugs and intra-aortic balloon pump. In all cases, the level of fibrinogen was less than 1 g X l-1. During the operation, the fibrinolysis was stopped by the intravenous injection of aprotinine (3,000,000 U X 2) and tranexamic acid (15 mg X kg-1), the coagulation factors used by the fibrinolysis being replaced by fibrinogen (1 g per litre of blood volume) and fresh plasma (6 to 8 packs in function of the haemodynamic state). Patient heparinization was as usual (300 IU X kg-1). At the end of the cardiopulmonary bypass, after injection of protamine, clotting quality was good and the fibrinogen level was more than 1 g X l-1. In the postoperative period, blood loss was of little importance. Coagulation troubles due to therapeutic fibrinolysis were reversible. It was possible to return quickly the patient's coagulation state to normal, and so carry out emergency coronary arterial surgery in a defibrinated patient. The indications for surgery depended on cardiogenic factors only.