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Background: The purpose of this study was to investigate the effect of preexisting atrial fibrillation on early and midterm clinical outcome in patients undergoing coronary surgery., Methods: All elective patients undergoing coronary artery bypass grafting surgery between April 1996 and September 2002 were investigated. Patients were grouped according to their preoperative cardiac rhythm: sinus rhythm (SR) or preexisting atrial fibrillation (AF). In-hospital clinical outcomes and 5-year patient survival and cardiac-related event-free survival were compared using regression methods to adjust for differences between the groups. In all, 5,092 patients were identified, 175 (3.4%) with a history of preexisting AF. These patients were older (median, 64 versus 68 years) and had higher Parsonnet scores (median, 4 versus 8) than the SR group. Previous myocardial infarction, cerebrovascular accident, hypertension, diabetes mellitus, renal impairment, peripheral vascular disease, ejection fraction less than 50%, previous surgery, congestive heart failure, and use of angiotensin-converting enzyme inhibitors were also more common in the AF group., Results: There were 60 in-hospital deaths (1.2%), with no difference between the two groups (odds ratio 1.02, 95% CI: 0.35 to 2.94). Atrial fibrillation patients were more likely to need intraoperative inotropes (p = 0.044), postoperative intra-aortic balloon pump (p = 0.038), and were less likely to be discharged within 6 days (p = 0.017). The risk of death in the 5 years after surgery was higher in the AF group (relative risk 1.49, 95% CI: 1.06 to 2.08, p = 0.020). In the AF group, 109 (62.2%) patients were cardioverted spontaneously by surgery, but only 69 (39.4%) remained in SR until discharge. Longer-term rhythm follow-up data were available for 48 of these 69 patients, and only 36 remained in SR at a median follow-up of 1,483 days (interquartile range, 1,120 to 2,209). Spontaneous conversion to SR after surgery did not confer a midterm survival benefit (p = 0.91)., Conclusions: Preexisting AF in patients undergoing coronary artery bypass graft surgery is not associated with increased in-hospital mortality and major morbidity; however, it is a risk factor for reduced 5-year survival. Spontaneous cardioversion to SR during surgery is transient in the majority of patients and is not associated with midterm survival benefit.

This review considers whether coronary artery bypass grafting (CABG) performed on the beating heart (off-pump or OPCAB) will supersede conventional CABG utilizing cardiopulmonary bypass (CPB) and cardioplegic arrest as the accepted gold standard. Randomized controlled trials, case-matched reports and observational studies have demonstrated lower morbidity in off-pump compared to conventional on-pump CABG with equivalent mid-term outcome at a significantly lower cost. Patients referred for surgical revascularization are increasingly elderly with more co-morbid medical conditions and elimination of CPB-related morbidity in these groups is associated with the most pronounced improvements in outcome, at least in observational studies. Long-term outcome, and in particular, long-term graft patency following OPCAB has not yet been reported. A barrier to the more widespread acceptance of OPCAB is the poor provision for training in off-pump techniques although structured cardiothoracic training that includes OPCAB surgery has been shown to be both possible and safe for patients. The evidence available to date therefore strongly supports the assertion that OPCAB may become the new gold standard in surgical revascularization. Whether it will ultimately replace conventional CABG, however, is dependent on the results of long-term patency studies and the wider development of adequate training programmes.

Background: Patients presenting with severe left ventricular (LV) dysfunction undergoing coronary artery surgery are at increased risk of perioperative morbidity and mortality. The present study investigated early and midterm outcomes in a consecutive series of patients with severe LV dysfunction undergoing coronary surgery at our institution., Methods: Data on 5,195 consecutive patients undergoing coronary artery bypass grafting (CABG) alone (in-hospital mortality 1.35%) from April 1996 to August 2002 were prospectively recorded in the Patient Analysis and Tracking System. Two hundred and fifty patients (median age 65 years [interquartile range, 57 to 70]) with preoperative left ventricular ejection fraction less than 30% (74 off pump; 29.6%) were identified and early and midterm clinical outcomes analyzed. Propensity scores were used to take account of the imbalance in the distribution of prognostic factors between the on-pump and off-pump groups., Results: Patients undergoing on-pump surgery were less likely to have current congestive heart failure, insulin-dependent diabetes, a history of hypertension, have had gastrointestinal tract surgery or an ulcer, or unstable angina. They had on average lower Parsonnet scores and New York Heart Association and Canadian Cardiovascular Score ratings. However they were more likely to have more extensive coronary artery heart disease and to require more grafts than those undergoing off-pump surgery. After adjustment for consultant team and propensity scores no differences between groups with regard to in-hospital mortality and morbidity were found. The only in-hospital outcome to show a significant difference after adjustment was the need for intraoperative inotropic support, which was higher in the on-pump group (odds ratio 5.1; 95% confidence interval 2.55 to 10.2; p < 0.001)). The median follow-up times for the on- and off-pump groups were 3.4 years and 1.4 years respectively. Three-year survival was higher with on-pump surgery (87% on-pump versus 73% off-pump) but this difference did not reach statistical significance after adjustment for prognostic variables (hazard ratio 0.54, 95% confidence interval 0.22 to 1.26, p = 0.16)., Conclusions: In-hospital mortality and morbidity in patients presenting with severe LV dysfunction is low with comparable results with both on- and off-pump coronary artery surgery. Midterm clinical outcome is encouraging and seems to justify surgical revascularization for this high-risk group of patients.

Background: Homocysteine (Hcy) is an independent risk factor for coronary artery disease, but there are no reports on Hcy levels in patients undergoing coronary artery bypass graft (CABG) surgery. Interactions between Hcy and copper may mediate the vasculopathic impact of Hcy, and this may play a role in vein graft failure. The aim of this study was to assess the perioperative levels of Hcy, copper, ceruloplasmin (CP), folate, and vitamin B12 in patients undergoing myocardial revascularization surgery., Methods: Blood samples were taken from 55 consecutive patients undergoing elective conventional CABG (43 male; mean age, 63.2 +/- 5.2 years) 1 day preoperatively and postoperatively at 1 day, 6 days, and 6 weeks. Hcy, copper, CP, red cell folate, vitamin B12, creatinine, and C-reactive protein (CRP) were then measured using standard clinical chemistry methods. The same protocol was applied to 10 patients (7 male; mean age, 63.3 +/- 5.2 years) undergoing off-pump coronary artery bypass (OPCAB) surgery., Results: In the conventional CABG group, there were significant increases in the plasma concentrations at 6 days and 6 weeks postoperatively of Hcy (from 10.1 to 11.6 and 13.5 micromol/L, respectively), plasma copper (from 13.5 to 20.3 and 18.5 micromol/L), and serum ceruloplasmin (from 0.3 to 0.41 and 0.44 g/L). CRP and vitamin B12 were elevated at 6 days but not 6 weeks after the operation. In contrast, red cell folate and creatinine were not significantly changed. The subgroup analysis for the OPCAB patients showed the same trend as for the conventional group., Conclusions: Coronary surgery precipitates a significant and sustained increase in the blood concentrations of Hcy and copper, which is not due to a decrease in folate and vitamin B12, altered renal function, or inflammation. Further studies are required to establish whether the concomitant increase in Hcy and copper plays an etiological role in vein graft disease.

Background: Off-pump coronary artery bypass surgery has been demonstrated to reduce morbidity in elective patients. However, high-risk patients might benefit the most from this surgical procedure. Our goal was to investigate the effectiveness of on-pump and off-pump coronary artery bypass surgery on early clinical outcome in a consecutive series of overweight patients., Methods and Results: From April 1996 to April 2001, data on 4321 patients undergoing coronary surgery (mortality 1.4%) were prospectively entered into the Patient Analysis and Tracking System. Data were extracted for all patients with a body mass index > or =25 kg/m(2). A risk-adjusted analysis was performed to assess the effect of surgical technique in the whole overweight cohort. 2844 patients were identified (2261 male, median age 63, interquartile range 56 to 68). Patients undergoing on-pump surgery (2170, 76.3%) were less likely than those undergoing off-pump surgery to have hypercholesterolemia or left main stem disease and were, on average, less obese. However, they were more likely to have unstable angina and to have had a previous myocardial infarction, and they had more extensive coronary disease and received more grafts (all P<0.05). Unadjusted analyses, taking account only of consultant team, showed significant benefits of off-pump surgery in terms of hospital deaths, arrhythmias, inotropic use, use of intra-aortic balloon pump, blood loss, transfusion requirement, postoperative hemoglobin, chest infections, neurological complications, intensive care unit and hospital stay (all P<0.05). After adjustment for confounding prognostic factors, the benefits of off-pump surgery were still significant for death in hospital, transfusion requirement, postoperative hemoglobin, neurological complications, intensive care unit and hospital stay (ORs 0.35 to 0.79, P<0.05)., Conclusions: These results suggest that off-pump surgery is safe and effective and is associated with a reduced in-hospital mortality and morbidity in overweight patients when compared with conventional coronary surgery with cardiopulmonary bypass and cardioplegic arrest.

Background: Although no randomised controlled trial has assessed the midterm effects of coronary-artery bypass surgery on the beating heart, this technique is being used in more and more patients. We did two randomised trials to compare the short-term morbidity associated with off-pump and on-pump myocardial revascularisation. Our aim was to pool the results to assess midterm outcomes., Methods: From March, 1997, to November, 1999, we randomly allocated 200 patients to off-pump and 201 to on-pump coronary surgery. In Beating Heart Against Cardioplegic Arrest Study (BHACAS) 1, we excluded patients who had had myocardial infarction in the past month or who required grafting of the circumflex artery distal to the first obtuse marginal branch. In BHACAS 2, we included such patients. Primary outcomes were all-cause mortality and cardiac-related events at midterm follow-up (1-3 years). Analysis was by intention to treat., Findings: Analyses of combined data from both trials showed the following risk differences with off-pump compared with on-pump surgery: atrial fibrillation -25% (95% CI -33% to -16%); chest infection -12% (-19% to -5%); inotropic requirement -18% (-25% to -10%); transfusion of red blood cells -31% (-41 to -21); and hospital stay longer than 7 days -13% (-21 to -5). Mean follow-up was 25 0 months (SD 9.1) for BHACAS 1 and 13.7 months (5 5) for BHACAS 2. Four (2%) of 200 patients in the off-pump groups died from any cause, compared with seven (3%) of 201 in the on-pump group (hazard ratio 0.57, 95% CI 0.17-1.96). 33 (17%) of 200 patients in the off-pump group died or had a cardiac-related event, compared with 42 (21%) of 201 in the on-pump group (0.78, 0 49-1.22)., Interpretation: Off-pump coronary surgery significantly lowers in-hospital morbidity without compromising outcome in the first 1-3 years after surgery compared with conventional on-pump coronary surgery.

Background: Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing conventional coronary artery bypass grafting. Off-pump coronary artery bypass operations have been shown to reduce renal dysfunction in patients with normal renal function, but the effect of this technique in patients with preoperative nondialysis-dependent renal insufficiency is unknown., Methods: From June 1996 to December 1999, data of 3,250 consecutive patients undergoing coronary artery bypass grafting were prospectively entered into the Patient Analysis & Tracking Systems (PATS, Dendrite Clinical Systems, London, UK). Two hundred and fifty-three patients with preoperative serum creatinine more than 150 micromol/L were identified (202 patients on-pump, 51 patients off-pump), and clinical outcomes were analyzed. Serum creatinine and urea, in-hospital mortality, and morbidity were compared between groups. The association of perioperative factors with acute renal failure was investigated by multiple logistic regression analysis., Results: Preoperative characteristics were similar between the groups. Mean number of grafts was 2.9 +/- 0.8 and 2.3 +/- 0.8 in the on-pump and off-pump groups, respectively (p < 0.0001). Comparison between groups showed a significantly higher incidence of stroke, inotropic requirement, blood loss, and transfusion of red packed cell and platelets in the on-pump group (all p < 0.05). Postoperative serum creatinine and urea were higher in the on-pump group with a significant difference at 12 hours postoperatively (p < 0.05). Logistic regression analysis identified cardiopulmonary bypass, serum creatinine level 60 hours postoperatively, inotropic requirement, need for intraaortic balloon pump, transfusion of red packed cell, and hours of ventilation as predictors of postoperative acute renal failure., Conclusions: This study suggests that off-pump coronary artery bypass operations reduce in-hospital morbidity and the likelihood of acute renal failure in patients with preoperative nondialysis-dependent renal insufficiency undergoing myocardial revascularization.

Background: The aim of this study was to compare hospital, early, and late clinical outcomes for patients undergoing one-stage, coronary and abdominal aortic surgical intervention with and without cardiopulmonary bypass., Methods: From March 1990 to September 1999, 42 consecutive patients underwent combined operations at a single institution. Cardiopulmonary bypass and cardioplegic arrest were used during coronary revascularization in the first 20 patients (on-pump group), and the next 22 patients received the one-stage operations on the beating heart (off-pump group)., Results: Baseline characteristics were similar between groups. Three cardiac-related hospital deaths occurred in the on-pump group and one such death in the off-pump group (p = 0.25). Cardiac-related events, pulmonary complications, inotropic support, blood loss and transfusion requirements, intensive care unit stay, and hospital stay were significantly reduced in the off-pump group (all, p < 0.05). The actuarial survival rates in the on-pump and off-pump groups were 80% and 95%, respectively, at 1 year (p = 0.13) and 75% and 89%, respectively, at 3 years (p = 0.22). Freedom from cardiac-related events at 1-year follow-up was 91% in the off-pump group and 65% in the on-pump group (p < 0.05). No difference in cardiac-related events between groups was observed at 3 years., Conclusions: Off-pump coronary surgical procedures decrease postoperative complications in high-risk patients undergoing simultaneous coronary and abdominal aortic operations compared with the conventional one-stage procedure. The early benefits achieved with off-pump surgical intervention are not at the expense of the long-term clinical outcome.

Objective: Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement., Methods: Two hundred patients with coronary artery disease were prospectively randomized to (1) on-pump treatment with conventional cardiopulmonary bypass and cardioplegic arrest and (2) off-pump treatment on the beating heart. Postoperative blood loss identified as total chest tube drainage, transfusion requirement, and related costs together with hematologic indices and clotting profiles were analyzed., Results: There was no difference between the groups with respect to preoperative and intraoperative patient variables. The mean ratio of postoperative blood loss and 95% confidence interval between groups was 1.64 and 1.39 to 1.94, respectively, suggesting on average a postoperative blood loss 1.6 times higher in the on-pump group compared with the off-pump group. Seventy-seven patients in the off-pump group required no blood transfusion compared with only 48 in the on-pump group (P <.01). Furthermore, less than 5% of patients in the on-pump group required fresh frozen plasma and platelet transfusion compared with 30% and 25%, respectively, in the on-pump group (both P <.05). Mean transfusion cost per patient was higher in the on-pump compared with that in the off-pump group ($184.8 +/- $35.2 vs $21.47 +/- $6.9, P <.01)., Conclusions: Coronary artery bypass grafting on the beating heart is associated with a significant reduction in postoperative blood loss, transfusion requirement, and transfusion-related cost when compared with conventional revascularization with cardiopulmonary bypass and cardioplegic arrest.

Objectives: To determine whether patients with critical left main stem (LMS) coronary artery disease can undergo off-pump coronary artery bypass (OPCAB) surgery safely and successfully., Methods: From May 1996 to March 2000 data for patients with critical (> or =50%) LMS stenosis who underwent conventional coronary artery bypass surgery with cardiopulmonary bypass (CCAB) or without (OPCAB) were collected prospectively using the Patient Analysis & Tracking System. A reusable pressure stabilizer, intra-coronary shunts and a single posterior pericardial stitch exposure technique were used in all OPCAB cases. Non-randomized, retrospective data analysis included demographic and preoperative risk factors, operative details, clinical outcome and early follow-up., Results: During the study period 387 patients with LMS stenosis underwent surgery (OPCAB n=75, CCAB n=312). Groups were similar in terms of preoperative and intraoperative variables although CCAB patients received significantly more grafts per patient (3.1+/-0.73 vs. 2.6+/-0.76, P< or =0.001). Mortality was similar in both groups (OPCAB 1.3% vs. CCAB 2.6%). OPCAB patients when compared to CCAB patients had a lower requirement for postoperative inotropes (12.0% vs. 38.1%, P=0.0001), temporary postoperative pacing (2.7% vs. 10.1%, P=0.02), and blood product transfusion (6.7% vs. 31.4%, P<0.0001), a lower incidence of postoperative chest infection (0% vs. 6.7%, P=0.02) and a slightly reduced postoperative length of stay (7.9+/-5.46 vs. 8.3+/-5.11 days, P=0.01). At 24 months follow-up, CCAB and OPCAB actuarial survival was 94.1+/-1.7% and 97.7+/-2.3%, respectively., Conclusions: OPCAB surgery is safe and effective in patients with critical LMS disease.

To determine the effects of beating heart surgery on patients undergoing simultaneous coronary artery bypass grafting and abdominal aortic surgery, we performed such surgery on 20 patients (mean age, 64.55+/-796 SD years). Abdominal aortic disease was defined as an abdominal aortic aneurysm larger than 5 cm in diameter or as end-stage aortic occlusive disease. Hemodynamic measurements, inotropic requirements, and incidence of perioperative myocardial infarction and arrhythmias were recorded, as were subsystem clinical outcomes, length of intensive care unit and hospital stays, blood loss, and transfusion requirements. There was no incidence of death, perioperative myocardial infarction, stroke, or acute renal failure. The mean number of grafts per patient was 1.95+/-0.69. Only 4 minor postoperative complications were observed: three patients (15%) had evidence of supraventricular tachyarrhythmias, and 1 patient (5%) had chest infection that required a longer-than-average intubation period. Six patients (30%) required minimal-to-moderate inotropic support. The mean blood loss was 673+/-246.8 mL and transfusion requirements were low. The mean intensive care unit and hospital lengths of stay were 2. 12+/-0.33 days and 708+/-1.44 days, respectively. Clinical follow-up (mean, 10 months) showed all patients to be in New York Heart Association functional class I or II with no late cardiac or abdominal events. We conclude that simultaneous coronary artery bypass grafting and abdominal aortic surgery on the beating heart is safe and effective, and has a low perioperative clinical morbidity rate. To our knowledge, ours is the 1st report on this procedure. Larger studies with longer follow-up are needed.

Coronary artery bypass surgery on the beating heart either via a left anterior small thoracotomy (LAST) or a median sternotomy is becoming increasing popular world-wide. Concern still remains about the potential for a temporary regional myocardial ischaemia associated with the stabilisation and occlusion of the coronary during construction of the anastomosis. This review summarises the results of a series of studies intended to evaluate the effect of beating heart coronary revascularization on myocardial function, myocardial tissue injury and clinical outcome.

Coronary artery fistula is a rare congenital malformation that can be complicated by intracardiac shunts, endocarditis, myocardial infarction, coronary aneurysm and sudden death. Clinical symptomatology depends upon the underlying anatomy and the size of the fistulous connection between the left or right side of the heart. We report the successful management of a giant right coronary artery with fistulization into the right atrium. Intraoperative transesophageal echocardiography with colour flow Doppler was used for precise location of the fistulous communication, selective demonstration of vessels feeding the fistula and documentation of abolition of fistulous flow all without the need for cardiopulmonary bypass. Furthermore the effect of shunt occlusion on regional wall motion was documented which facilitated the successful ligation of the fistula.

Objective: Conventional coronary artery bypass grafting (CABG) is both safe and effective. Nevertheless, the use of cardiopulmonary bypass (CPB) and cardioplegic arrest are associated with several adverse effects. Over the last 2 years there has been a revival of interest in performing CABG on the beating heart. In this prospective randomized study we evaluated the efficacy and safety of on and off pump coronary revascularization on myocardial function., Methods: Eighty patients (65 males, mean age 61+/-9.7 years) undergoing first time CABG were prospectively randomized to: (i) conventional revascularization with CPB at normothermia and cardioplegic arrest with intermittent warm blood cardioplegia (on pump) or (ii) beating heart revascularization (off pump). Troponin I (Tn I) release was serially measured as a specific marker of myocardial damage. Haemodynamic measurements as well as inotropic requirement, incidence of arrhythmia and postoperative myocardial infarction were also recorded., Results: There were no significant differences between the two groups in terms of age, sex, extent of disease, left ventricular function and number of grafts. There were no deaths or intraoperative myocardial infarctions in either group. Tn I release was constantly lower in the off pump group and this was significant at 1, 4, 12 and 24 h postoperatively. Furthermore, in this group there was a significantly reduced incidence of arrhythmias. Inotropic requirements were less in the off pump group but this did not reach statistical significance., Conclusion: These results suggest that off pump coronary revascularization is a safe and effective strategy for myocardial revascularization. Myocardial injury as assessed by Tn I release is also reduced when compared with conventional coronary revascularization with CPB and cardioplegic arrest.

Objective: Activation of both complement and neutrophils has been demonstrated to be involved in many pathological reactions following cardiopulmonary bypass (CPB). The aim of the present study is to evaluate the effect of normothermic and hypothermic CPB on both complement and neutrophil activation., Methods: Two groups of patients (n = 20 each) scheduled for elective coronary artery bypass grafting, underwent CPB with intermittent warm or cold blood cardioplegia. Plasma concentration of C3a, C5a and C5b-9, as well as nitro-blu tetrazolium (NBT) scores of circulating neutrophils were measured before anesthesia, 10 and 30 min after the beginning of CPB, and 8, 16 and 24 h, postoperatively., Results: In both groups, CPB determined a significant complement activation, evidenced as a significant increase in plasma concentration of C3a, C5a and C5b-9. This in turn triggered the neutrophil activation, documented as a significant increase of NTB scores in circulating neutrophils at the end of CPB and in the early postoperative period. Interestingly, in the warm group the extent of both complement and neutrophil activation was significantly higher compared with the cold group during the whole sampling period., Conclusion: In conclusion, our study clearly demonstrates that warm CPB is associated with an increased ability to activate complement and neutrophils in patients undergoing coronary surgery.

Aim: To report on the use of a third-generation bileaflet mechanical valve in septuagenarians, selected to receive a mechanical valve, as compared to (a) a younger cohort undergoing same valve implant (study 1) and to (b) a matched group of septuagenarians undergoing biological implant (study 2). Methods: The study was carried out in a tertiary regional hospital in South-West England. Study 1: Consecutive series of 567 patients undergoing Sorin Bileaflet (SB) mechanical valve implant (437 patients < 70 years; 130 patients ≥ 70 years). Study 2: 113 septuagenarians undergoing biological implant matched on age, valve type, concomitant coronary surgery, and operative priority to the SB septuagenarian group. Main outcome measures included in-hospital mortality and morbidity and mid-term valve-related outcome. Results: Study 1: Septuagenarians were more likely to present with coronary disease, and to undergo coronary surgery (p < 0.01). In-hospital mortality was 2.8% and 2.3% (p = 0.79) and neurological complications 1.4% versus 3.8% (p = 0.026) in the younger and older groups, respectively. Valve-related mortality at two years was 1.8% (95%CI, 0.8% to 3.6%) and 4.8% (95% CI, 2.0% to 9.7%); cumulative three- year incidence of thromboembolic or major hemorrhagic event was 8.3% (95% CI, 5.7% to 12.0%) and 4.6% (95% CI, 1.7% to 12.4%) in the younger and older groups, respectively. Study 2: In-hospital mortality was 1.8% and 7.1% in the SB and biological groups, respectively (ratio 0.25; 95% CI, 0.05 to 1.18, p = 0.058). The incidence of acute renal failure was greater in the biological group (risk ratio 0.30; 95% CI, 0.09 to 0.98, p = 0.035). There was no difference in mid-term valve-related mortality between groups (hazard ratio 0.53; 95% CI, 0.18 to 1.52, p = 0.24). Conclusion: The performance of SB valve in septuagenarians seems to be effective with no increased risk of in-hospital mortality, bleeding, or thromboembolic events. [ABSTRACT FROM AUTHOR]