Summary
One-hundred and twenty patients with severe coronary artery disease were anaesthetized for a revascularization procedure. The over-all mortality rate was 13.4 per cent. The preoperative assessment, anaesthetic management and postoperative care of these patients have been described. The experience has been helpful in managing patients with coronary artery disease for any type of surgery.
A normal electrocardiogram at rest is of no value in predicting the severity of coronary artery disease. It was normal in three of 16 men who died, and severe disease was demonstrated in these patients.
Hypotension was avoided as far as possible by meticulous attention to the anaesthetic technique, fluid and blood replacement. When hypotension occurred it was immediately corrected by the judicious use of phenylephrine.
Angina at rest without exciting cause was the most important single factor that could be related to mortality. The mortality in patients with angina grade II (angina at rest without exciting cause) was 32.2 per cent as compared to 5.8 per cent in patients with angina grade I ( angina other than grade II ).
Two patients had had a clinical infarct six months before surgery with angina grade I and both died in the operating room. Two patients at autopsy were found to have had an undiagnosed infarct two to three weeks prior to surgery.
Associated diseases which contributed to mortality were hypertension, diabetes and myxedema, cerebral vascular insufficiency, pulmonary insufficiency, and digitalis intoxication associated with hypokalaemia.
Résumé
Cent vingts malades, sérieusement atteints de troubles coronariens ont été soumis à une anesthésie pour subir une revascularisation du myocarde. Le taux général de mortalité a été de 13.3 pour cent. Nous avons parlé de éévaluation préopératoire, de la conduite de l’anesthésie et des soins postopératoires de ces malades. Ce fut une expérience enrichissante que de traiter des porteurs de maladies coronariennes au cours de diverses opérations.Un tracé électrocardiographique, fait au repos, ne possède aucune valeur pour donner une idee de la sévérité de l’atteinte des coronaires. Le tracé était normal chez trois des 16 patients qui sont morts et qui étaient porteurs de maladies graves de leurs coronaires.
Autant que possible, nous avons évité toute hypotension en prenant des précautions minutieuses pour la technique de l’anesthésie et le remplacement des fluides et du sang. S’il survenait une baisse de la pression, nous la corrigions instantanément en administrant de façon judicieuse de la phénylephrine. L’angine, au repos, sans cause provocatrice, a été le plus important facteur unique se reliant à la mortalité.
La mortalité dans le groupe de malades porteurs d’angine grade II ( angine au repos sans cause provocatrice) a atteint un pourcentage de 32.2 alors que le taux était de 5.8 pour cent chez les malades porteurs d’angine grade I (angine hors du grade II ).
Deux malades avaient eu un infarctus clinique six mois avant la chirurgie et ils étaient porteurs d’angine grade I; les deux sont morts dans la salle d’opéVation. A l’autopsie nous avons découvert que deux malades avaient eu un infarctus méconnu ou ignoré deux ou trois semaines avant la chirurgie.
Les différentes pathologies qui ont contribué à augmenter le taux de mortalité sont: l’hypertension, le diabète, le myxoedème, l’insuffisance circulatoire cérébrale, l’insuffisance respiratoire et l’intoxication digitalique associée à l’hypokaliémie.
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Wynands, J.E., SheRidan, C.A. & Kelkar, K. Coronary artery disease and anaesthesia (Experience in 120 patients for revascularization of the heart). Can. Anaes. Soc. J. 14, 382–398 (1967). https://doi.org/10.1007/BF03003801
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DOI: https://doi.org/10.1007/BF03003801