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Ann Thorac Surg 1992;54:1065-1070
© 1992 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, University of Texas Medical School and The Hermann Hospital, Houston, Texas, USA
* Address reprint requests to Dr Sweeney, Department of Thoracic and Cardiovascular Surgery, University of Texas Medical School, MSMB 1.222, 6431 Fannin, Houston, TX 77030.
Although advances in both the technology of artificial oxygenation and our understanding of myocardial preservation have made aortocoronary bypass operations safer, clinical settings remain where even these improvements have limited efficacy. We have recently treated 43 severely ill patients with aortocoronary bypass, using a ventricular assist device for intraoperative hemodynamic support and ventricular decompression. For 34 of the patients, preoperative ejection fractions (multigated acquisition) ranged from 0.12 to 0.28 (average, 0.22); 6 patients manifested cardiogenic shock preoperatively, and emergency operations precluded multigated acquisition studies. Twenty-nine patients had preoperative evidence of congestive heart failure, 10 had a prior bypass operation, 9 had major chronic obstructive pulmonary disease, and 2 were Jehovah's Witnesses. The operative technique involved minimal doses of heparin (1 to 1.5 mg/kg), no cardioplegia, and no cardiopulmonary bypass. Revascularization was accomplished on beating, nonworking hearts, with right (40 of 43) and left (43 of 43) ventricles supported by Nimbus Hemopumps (4 of 43) or Bio-Medicus centrifugal ventricular assist devices for an average of 112 minutes. In each case, the patient's lungs were used as the oxygenator. An average of 3.7 bypass grafts per patient were constructed. The left internal mammary artery was used in 41 patients, whereas at least one coronary endarterectomy was required in 20. Six patients had concomitant placement of an automatic implantable cardioverter defibrillator. Two patients (4.6%) died: 1 (with preoperative cardiogenic shock) of low cardiac output on postoperative day 1, and 1 of a severe neurologic deficit on day 8. Follow-up ranged from 2 to 18 months (average, 8.9 months), with all survivors demonstrating improvement in cardiac function in both the early and late pestoperative periods. We believe that the use of ventricular assist device support for myocardial revascularization has real efficacy, especially in the management of severely ill, high-risk patients at increased operative risk. Moreover, we are encouraged that in selected cases, avoiding pump oxygenation and cardioplegia-induced global ischemic arrest may be a safe strategy.
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