Background and Aims: Understanding and objective assessment of risks is crucial in cardiac surgery. The aim of this study was to assess the influence of peripheral vascular disease (PVD) on morbidity, mortality and outcome in coronary artery bypass grafting (CABG) patients.Material and Methods: The ankle-brachial pressure index (ABPI) was used as indicator of PVD and was measured in 178 CABG patients. Two groups were established: 1. normal ABPI (0.9-1.3) (n =136) and 2. lowered ABPI (< 0.9) (n =35). The mean follow-up was 26 months.Results Conclusions: The presence of PVD is relatively high in CABG patients and increases with age. PVD predicts some morbidity but seems to have fairly little influence on shortterm or middle-term outcome of CABG patients. ABPI may be of only limited value in identifying patients with high operative risk in CABG.

We have reviewed the results of our experience with the use of miniaturized (Mini-CPB) versus conventional (C-CPB) cardiopulmonary bypass in coronary artery bypass surgery (CABG). This study included 365 patients who underwent CABG with C-CPB and 101 patients with Mini-CPB. In-hospital mortality was lower in the C-CPB group (1.4% vs. 3.0%, P = 0.38). A better, but not statistically significant, immediate outcome was observed in the C-CPB group as indicated by a shorter length of stay in the intensive care unit as well as a lower incidence of combined adverse end-point. However, this was probably due to significantly higher operative risk in the Mini-CPB group (logistic EuroSCORE: 8.5 +/- 10.0 vs. 4.6 +/- 7.1, P < 0.0001). Seventy-seven propensity score-matched pairs had similar immediate postoperative results after Mini-CPB and C-CPB (30-day mortality: 1.3% vs. 1.3%; stroke: 0% vs. 0%; intensive care unit stay > or = 5 days: 6.5% vs. 9.1%; combined adverse events: 14.3% vs. 11.7%). Mini-CPB achieves similar results to C-CPB in patients undergoing isolated CABG. The potential efficacy of Mini-CPB is expected to be more evident in high-risk patients or in complex cardiac surgery requiring much longer cardiopulmonary perfusion.

Objective: The goal of this study was to examine the metabolic and hemodynamic effects of a glucose-insulin-potassium infusion in elective coronary surgery, when blood cardioplegia was used for cardiac protection. Design and Patients: A prospective, randomized, open, clinical comparison was performed between 2 perioperative infusion regimens in 40 elective nondiabetic coronary artery bypass graft (CABG) surgery patients. Setting and Interventions: 20 patients (glucose-insulin-potassium – GIK – group) received glucose 0.2 g/kg/h, insulin 0.12 U/kg/h, potassium 0.15, magnesium 0.032 and phosphate 0.024 mmol/kg/h from anesthesia induction to the start of bypass, when infusion rate was reduced to 30%, and after bypass increased to 50% of the initial rate. The infusion was continued until the first postoperative morning. Another 20 patients (control – R – group) received glucose 0.05 g/kg/h, potassium 0.075, magnesium 0.016 and phosphate 0.008 mmol/kg/h from the end of bypass to the next morning. Pump prime was glucose-free and a blood cardioplegia technique was used for cardiac protection. Results: The GIK patients needed less dopamine support in the intensive care unit (ICU) (p < 0.05). No difference was found between the groups with regard to myocardial injury, the MB-fractions of serum creatine kinase (CK-MB) being elevated to a similar degree in both groups. Likewise there were no significant differences in hemodynamic changes or duration of ICU stay. Although the glucose infusion was continued during bypass in the GIK patients, there was a considerable risk of hypo-glycemia (due to insulin and hemodilution) after the onset of bypass: in 5 GIK patients (25%; 95% confidence interval 8.7 to 49.1%) blood glucose was less than 2 mmol/l. However, the hypoglycemia was of short duration and no detrimental effects were seen. Conclusions: Perioperative GIK infusion entailed a slight decrease in the postoperative need for dopamine support, but was connected with a considerable risk of hypoglycemia.

The incidence of stroke seems to be on the same level in CABG patients from a low volume hospital as in reports from centres with a high volume of annual procedures. Stroke predicts higher mortality, longer intensive care unit (ICU) stay, longer hospitalisation and poorer survival. A relatively high number of stroke patients need permanent institutional care. Satisfaction-based quality of life in CABG patients also remains on a lower level in comparison to patients without neurological complications.

Objective: The goal of this study was to assess the effects of a combination of glucose-insulin-potassium (GIK) and the amino acids aspartate and glutamate upon perioperative hemodynamics in coronary surgery patients with unstable angina and/or compromised left ventricular function. Design: Prospective, randomized, and double-blind clinical study.Setting: Operating theatre and intensive care unit (ICU) of a university hospital. Patients: 44 coronary artery bypass graft (CABG) patients with unstable angina and/or compromised left ventricular function. Interventions: 22 patients (group A) were given 11 of an infusion with 250 g glucose, 100 I.U. fast-acting human insulin, 72mmol potassium, 32 mmol magnesium, 20 mmol phosphate, 65 mmol aspartate, and 65 mmol glutamate, while another 22 patients (group C) were given 11 of an infusion with 50 g glucose, 72 mmol potassium, 32 mmol magnesium, and 8 mmol phosphate. The infusion rate was 1.2ml/kg/h from the anesthesia induction onward to the commencement of cardiopulmonary bypass, when it was reduced to 0.8ml/kg/h. When 11 had been infused, but not later than 4 a.m., the infusion was continued by giving 10% glucose at the same rate to both groups. Additional insulin (median: 14.21.U., range: 0-41.5) or saline was given during bypass to the A and C patients, respectively. A blood cardioplegia technique containing aspartate and glutamate was used in both groups. Results: At aortic cannulation, the cardiac index (CI) had increased from the pre-anesthetic level by 15.3% (mean) (SD: 31.7%) in group A and decreased by 7.7% (15.1 %) in C patients, p = 0.0069. Also the changes in stroke index (SI; p = 0.022), left (LVSWI; p = 0.0037) and right ventricular stroke work index (RVSWI; p = 0.0097) were more favorable in group A. Despite longer aortic cross-clamp, p = 0.031, and perfusion times, p = 0.042, in A patients, the change in cardiac index was also better in this group after bypass: At decannulation, the difference between mean values was 31.8%, p = 0.0001, and at arrival in the ICU it was 16.1%, p = 0.028. The same was also seen 8h postoperatively and on the 1st and 2nd postoperative mornings; p = 0.034, 0.040, and 0.037, respectively (Wilcoxon test). Favorable changes were seen for the A patients also regarding SI at decannulation (p = 0.0002) and after 8 h (p = 0.017); LVSWI at decannulation (p = 0.0002), at arrival in the ICU (p = 0.0023), and after 8h (p = 0.0011); and RVSWI at decannulation (p = 0.0027), at the ICU (p = 0.021), after 8h (p = 0.014), and on the 1st postoperative morning (p = 0.039). However, the response to a hemodynamic loading test (6% hydroxyethyl starch 5 ml/kg) was similar in the 2 groups, and there was no difference in the need for inotropic support. Conclusions: Amino acid-enriched GIK infusion improves hemodynamic function in CABG patients with unstable angina and/or compromised left ventricular function.