Surgical management of complex acquired cardiovascular disease

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The most common forms of complex acquired cardiovascular disease associated with coronary artery disease that require surgical treatment are either the serious manifestations of systemic atherosclerosis such as coexistent carotid stenosis, abdominal aortic aneurysm, or other peripheral vascular disease; or alternatively, the cardiac complications of coronary atherosclerosis such as ischemic cardio-myopathy, left ventricular aneurysm, mitral insufficiency, or postinfarction ventricular septal defect.

As regards the former group of conditions, it is well recognized that patients with coronary atherosclerosis are at greater risk of myocardial infarction and death from major surgery. In one study of 587 patients with previous myocardial infarctions who underwent various operations, 6.1% (36/587) of patients had recurrent myocardial infarctions and the operative mortality was 4.3% (25/587).1

In contrast to these results has been the favorable outcome in relation to mortality and myocardial infarction in patients with functioning coronary bypass grafts who have undergone subsequent major surgical procedures. In a review of a series of 358 such patients operated on at Baylor College of Medicine, perioperative (30-day) mortality was 1.1%, and the incidence of perioperative myocardial infarction was 1.6%.2 We have also reviewed our experience with the treatment of coexistent carotid and coronary artery disease.3 Of those patients with a history of angina and documented coronary disease who did not undergo coronary bypass prior to carotid endarterectomy, operative mortality was 18.2% (14/77), almost all due to myocardial infarction. However, in patients who underwent prior or simultaneous coronary bypass and then carotid endarterectomy, operative mortality was reduced to 3% (4/135) . . .



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