Complex cases in cardiac surgery.

Between January, 1968, and January, 1993, 790 patients underwent cardiac operations that were either complex or performed in the presence of a life threatening disease of other vital organs. There were 73 (9.2%) operative deaths (d; < thirty days). A substantial number (n) of the operations (30 or more) and associated operative deaths included left ventricular (LV) aneurysmectomy or plication (LVA-P) with coronary artery bypass (CAB) grafts with, or, without other cardiac procedures (OCP; n = 261; d = 11.1%), cardiac reoperations (n = 65; d = 4.6%), CAB grafts plus mitral or aortic valve replacement (n = 59; d = 1.7%), combined mitral and aortic valve replacement (MAVR) with, or without tricuspid valve (TV) replacement and CAB grafts (n = 52; d = 7.7%), CAB grafting for an end-stage coronary artery disease (CAD; n = 40; d = none), emergency CAB grafts for an acute myocardial infarction (MI) with cardiogenic shock (n = 37; d = 24.3%), complex internal thoracic artery (ITA) grafting (n = 30; d = none), and miscellaneous (n = 43; d = 2.3%). The best results were achieved in CAB grafts for an end-stage CAD, complex ITA grafting, CAB grafts plus mitral or aortic valve replacement, cardiac reoperations, MAVR, and miscellaneous. This is probably related to an intensive treatment of congestive heart failure (CHF) before the operation, pretreatment with the oxygen free radical inhibitor (allopurinol), selective use of an intraaortic balloon assist (IABA) device, routine use of hemoconcentrator (ultrafiltration, UF) during cardiopulmonary bypass (CPB) in those with CHF, thorough myocardial protection, and a complete left-sided plus right-sided coronary revascularization.