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The mental strain of a cardiac surgeon may differ when he performs coronary surgery from and when he only assists in performing coronary surgery. In 50 selected cases of on-pump heart arrested coronary artery bypass grafting (CABG), an attending-consultant surgeon performed 30 procedures of CABG (Group A) and an attending-consultant surgeon supervised the remaining 20 cases of CABG performed by two resident surgeons (Group B). Intraoperative Holter electrocardiograms of the attending-consultant surgeon were recorded and analyzed for heart rate variability (HRV). In Group A, the ratio of low frequency to high frequency was at a peak in the beginning of the operation and gradually decreased toward the end of the operation. In Group B, the ratio of low frequency to high frequency was at a peak in the phase of aortic cross-clamp, coronary anastomosis, and unclamping. When an attending-consultant surgeon performed the operation himself, the most anxious part of the operation was at the beginning and thereafter the level of anxiety gradually declined. In contrast, when he assisted a resident, the highest level of anxiety was when the aortic cross-clamp was in place and out of place and during the coronary anastomosis.

Effort angina of a 70-year-old man was diagnosed as due to triple coronary vessel disease, and he was scheduled to undergo coronary artery bypass surgery. Preoperative carotid duplex scan revealed more than 75% stenosis of the right internal carotid artery, which was functionally proven to be significantly ischemic on brain single photon emission computed tomography. Although he was neurologically asymptomatic, we chose staged surgery for fear of stroke during coronary artery bypass surgery. He had successful carotid artery stenting first by neurosurgeons; then, 2 months later he underwent uneventful coronary artery bypass surgery. This experience prompted us to report the case.

Background: Transit time flow measurement has been accepted as a valuable tool to predict early coronary artery bypass graft failure immediately after surgery. However, if the graft is patent in the early postoperative period, the ability of transit time flow measurement to predict midterm graft failure is unknown., Methods: Midterm postoperative angiography was performed between 1 and 4 years after surgery for 104 grafts, which were evaluated by intraoperative transit time flow measurement and confirmed to be fully patent in early postoperative angiography., Results: Of the 104 grafts, 21 grafts were found to have a new, midterm occlusion or worsening of stenosis. Univariate analysis revealed that a lower mean flow (odds ratio 0.96 per flow unit, mL/min, p < 0.001) and a higher percentage of backward flow (odds ratio 1.08 per percentage point, p < 0.05) measured by transit time flow measurement was a risk factor for predicting midterm graft failure. An increasing interval between the surgery and the midterm angiography was also a predictive risk factor (odds ratio 1.06 per month, p < 0.05). In the multivariate stepwise logistic regression analysis, a lower mean flow was found to be the independent risk factor for midterm graft failure (p < 0.01). A venous graft and an increasing interval between surgery and midterm angiography were also found to be possible risk factors., Conclusions: Transit time flow measurement provides a good prognostic index, not only for the immediate term but also for the midterm follow-up. A graft with intraoperative lower mean flow, and especially with a higher percentage of backward flow, should be carefully monitored, even if it was initially anatomically patent.

Background: A primary limitation of using transit time flow measurement to predict early graft failure in coronary artery bypass grafting has been the lack of cutoff values for objective criteria., Methods: We analyzed a total of 261 grafts that were evaluated by intraoperative transit time flow measurement and underwent early postoperative coronary angiography within 3 months of surgery. Based on the control angiography, failing grafts were defined as occluded or patent grafts with greater than 50% stenosis or poor flow characteristics. Normal and failing graft indicators were compared according to the graft territories., Results: According to the receiver operating characteristic curve analysis for the grafts to left coronary arteries, a mean flow of 15 mL/min or less, a pulsatility index of 5.1 or higher, and a backward flow of 4.1% or higher were found to be the optimal cutoff criteria to predict early graft failure. Similarly, for the grafts to right coronary arteries, the cutoff values were 20 mL/min, 4.7, and 4.6%, respectively. A systolic dominant flow curve pattern was a risk factor only in grafts to the left coronary arteries. Negative predictive values of these cutoff criteria ranged from 0.91 to 0.96, whereas positive predictive values ranged from 0.31 to 0.80., Conclusions: Using these criteria, transit time flow measurement may be a useful method to predict early graft failure. However, surgeons should be aware of the low positive predictive values to avoid unnecessary graft revision.

Side-to-side anastomosis was employed by just ten proportional stitches while performing distal anastomosis during coronary artery surgery. This technique is simple and quick. Here this simple technique is described in detail and the postoperative status of grafted conduits is reported.

Because a suction-type stabilizer does not move once it is attached to the heart in either on-pump or off-pump coronary surgery, we have been using a simple method of stabilizing mammary radial, or epigastric artery grafts with a suction stabilizer in anastomosis of coronary artery grafts. This method excludes the need for assistants to hold the graft, which can bel cumbersome, thereby reducing graft movement. This experience prompted us to report this method.

To provide supplementary training for trainee cardiac surgeons, a simple method is required to simulate coronary anastomoses. By stretching 2 gloves over a towel, a model can be made that can be used to simulate a small coronary arteriotomy (including anterior and posterior walls). The graft can also be simulated using the fingers of the gloves.

Objective: Case-volume has been believed to be of paramount importance in becoming a good cardiac surgeon. However, for a training cardiac surgeon there is no evidence regarding the specific number of necessary cases to attain the medico-legally acceptable level. We attempted to observe the learning curve in performing coronary surgery with the use of the cumulative sum (CUSUM) method to provide some evidence., Methods: From April 2000 to March 2004, a cardiac surgeon, being board-certified but not being on the attending staff, performed 50 coronary artery bypass grafting (CABG) under supervision of three different chief attending surgeons at three different hospitals. His learning curve was analyzed with the use of CUSUM. Mortality and morbidity and the average time of crossclamp and operation at each hospital were examined. Also, the learning curve of 100 left internal mammary artery (LIMA) harvestings were analyzed via CUSUM in terms of harvesting time and injury rate., Results: The CUSUM curve tended to come closer to the alert line (0.80 confidence) until the 23rd case, but never reached the alert line thereafter until the 50th case. The CUSUM curve never transgressed the alarm line (0.95 confidence) throughout 50 cases. The CUSUM curve of LIMA harvesting approached the alert line in the 38th case and the 59th case, but thereafter never reached the alert line and remained below the reassurance line from the 73rd case., Conclusion: Tentatively, it is inferred that approximately 23 cases of CABG may be sufficient to allow for independent practice and that 73 cases of LIMA harvesting are sufficient to allow independent practice.

Background: The new evolving multidetector computed tomography (MDCT) is thought to be promising in imaging of coronary disease. We compared the evaluating power of MDCT to that of conventional coronary artery angiogram in patients with coronary artery bypass grafting surgery., Methods: From April 2002 to December 2003, 50 patients underwent both MDCT and coronary artery angiogram after coronary artery bypass surgery. Overall, 170 grafts were studied. Two weeks after the surgery, 8-row MDCT was taken using contrast medium to observe the grafts patency. Three weeks after the surgery, conventional coronary angiogram was done to verify the graft status. The graft status was classified according to Fitzgibbon classification. Sensitivity, positive predictive value, and negative predictive value were calculated and compared., Results: Multidetector computed tomography succeeded in high-quality imaging of all grafts except for one (less than 1 mm gastroepiploic graft to posterior descending artery). This graft was the only graft that was interpreted differently. Overall patency rate was 97.8%. The diagnostic power of MDCT was as follows: the specificity was 99.4%, the sensitivity was 100%, the positive predictive value was 100%, and the negative predictive power was 80%., Conclusions: In this study, 8-row MDCT showed reliable imaging power in verifying grafts status. Since MDCT is much less invasive for patients, conventional coronary artery angiogram will be substituted by evolving MDCT.

A 66-year-old woman with a 30-year history of Behcet's disease was referred for coronary surgery because of restenosed stent and crescendo angina. We succeeded in operating on her by off-pump coronary bypass with bilateral internal mammary arteries, which were anastomosed to the left anterior descending artery and diagonal artery. The grafts were patent postoperatively and she became free from angina. Coronary surgery for Behcet's disease is extremely rare and this experience prompted us to report this case.

Atrial natriuretic peptide and brain natriuretic peptide are known to be indices for heart failure. Atrial natriuretic peptide and brain natriuretic peptide changes in off-pump and on-pump coronary artery bypass grafting is hypothesized to be correlated to clinical implications of coronary artery bypass grafting. 20 consecutive off-pump and 20 consecutive on-pump coronary artery bypass grafting patients were studied. Perioperative atrial natriuretic peptide and brain natriuretic peptide values were measured and statistically analyzed in terms of 14 factors related to myocardial damage and recovery. Postoperative atrial natriuretic peptide plateaued on the third postoperative day and it decreased gradually down to the preoperative level by one month in the off-pump group. Postoperative brain natriuretic peptide plateaued, showed very slow decrease and it never reached down to the preoperative level. The peak brain natriuretic peptide level was correlated with aortic cross-clamp time, postoperative pleural effusion, and postoperative atrial fibrillation (p < 0.01). The atrial natriuretic peptide change reflected surgical prevention of ventricular remodeling. Brain natriuretic peptide > 450 microg.mL(-1) had strong predictive power for atrial fibrillation and pleural effusion and is a useful marker for management of coronary surgery patients.