Thrombelastographic changes in OPCAB surgical patients

The purpose of this study was to determine whether thrombelastography could detect hypercoagulability in the off-pump coronary artery bypass (OPCAB) patient. Seventeen OPCAB and six cardiopulmonary bypass (CPB) patients were studied pre- and postprocedure, as well as on each of the first three postoperative days (POD). In the OPCAB patients, there was a small reduction in the postprocedure coagulation index (CI). This was followed by an increase in the CI on each of the next three POD, reaching a level exceeding the mean preprocedure CI by 2.32 units, indicative of a state of relative hyper- coagulability. The mean CI for the CPB patients decreased significantly in the postprocedure sample. Over the next 72 h, the CI increased to a level that nearly equaled the preprocedure ‘baseline’. We concluded that our study identified a state of relative hypercoagulability in the OPCAB patient 72 h after surgery. The mechanism of this hypercoagulation, as well as the clinical significance of this finding, is yet to be determined.

Creative arterial bypass grafting can be performed on the beating heart

BACKGROUND

To demonstrate that compromise is unnecessary in either the design or performance of beating heart surgery, we report our experience, over 1 year, of total arterial revascularization where composite or creative grafting was utilized.

METHODS

We performed 321 off-pump coronary artery bypass operations, of which, 290 (90%) were done with only arterial conduits. The mean number of distal anastomoses was 2.48, with a range of 1 to 5. There were no aortic anastomoses. One hundred eighty-nine patients (65%) were male, and 101 (35%) were female, with a mean age of 67 years. Comorbidities included chronic renal failure (CRF), 21 (7%); diabetes, 92 (32%); obesity, 68 (23%); hypertension, 212 (73%); chronic obstructive pulmonary disease, 189 (65%); cerebral vascular accident (CVA), 39 (13%); smoking, 164 (56%); and hypercholesterolemia, 151 (52%). The mean ejection fraction was 56%, with a range of 21% to 71%. All procedures were performed with external stabilizers with or without vacuum assist. The complete arterial revascularizations included a T-graft (internal thoracic [ITA]/radial arteries [RA]), 130 (45%); a sequential graft (ITA +/- RA), 118 (41%); a U-graft (coronary-coronary graft perfused by the ITA or right gastroepiploic artery), 5 (2%); an I-graft (ITA/RA), 4 (1%); an X-graft (ITA/RA), 2 (12); and a Y-graft (ITA/RA), 31 (10%).

RESULTS

The postoperative incidence of atrial fibrillation was 80 of 290 (27%); CVA, 5 of 290 (2%); bleeding resulting in take-back, 5 of 290 (2%); CRF, 8 of 290 (3%); deep sternal infection, 4 of 290 (1%); and readmission (30-day) for angina, 4 of 290 (1%). The observed perioperative (30-day) mortality was 9 of 290 (3.1%), with the STS predicted rate of 3.82%.

CONCLUSIONS

Our experience indicates that once the operating surgeon has learned to safely expose the lateral and inferior walls of the heart, the type of conduit and the method of revascularization should be no different than that used with cardiopulmonary bypass. However, we still recommend conventional methods of revascularization (on-pump with saphenous vein conduits) for the ischemic patient.

Traumatic occlusion of two radiocephalic fistulas: case reports and their management

The number of ambulatory dialysis patients is increasing each year with a concomitant rise in extremity access fistulas and grafts. The anatomic location of these fistulas makes them particularly susceptible to traumatic occurrences. Management of traumatic occlusion of these fistulas becomes a critical issue in allowing continuing dialysis in these patients. Management of two such patients is presented.