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Query: UMLS:C0002962 (angina)
 21,142 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Massive obesity is associated with serious co-morbidities. After failure of extensive conservative measures, surgical procedures have developed as the only successful method for sustained weight loss. Criteria for operation are: presence of serious diseases associated with morbid obesity; greater than 45 kg above ideal weight or body mass index greater than 40 kg/m2 for usually greater than 5 years; failure of sustained weight loss on extensive conservative regimens; commitment to lifelong follow-up; and acceptable operative risk. Angina pectoris itself is not a contraindication to these operations. Patients who do not quite meet the weight criteria may still be candidates for an obesity operation in certain instances, e.g., debilitating musculoskeletal pains in weight-bearing joints, diabetes, significant hypertension, reflux esophagitis, urinary stress incontinence. Although current operations result in lasting weight loss of greater than 50% of excess weight in the majority of patients, the surgical candidate must understand and accept the principles of the procedures, the potential for serious complications, the dietary necessities, and occasional failures.
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PMID:Morbid obesity: selection of patients for surgery. 150 8

Most analyses of risk factors affecting survival after coronary artery bypass graft surgery have not differentiated among factors that influence early and late survival. For this reason, a multiphase model was applied to survival data from 2,967 patients undergoing a first coronary artery bypass graft at the Duke University Medical Center between 1969 and 1984. There were 709 deaths during follow-up to 19.6 years. The data were analyzed using a multivariable survival model that separates the underlying hazard function into as much as three different phases, each incorporating separate risk factors. Two distinct phases were detected. One phase dominated early survival (0-1 year), and the second phase dominated late survival (greater than 1 year). Surgery performed earlier in our experience was associated with elevated risk of dying in both phases but with different magnitudes, whereas lower ejection fraction, greater extent of coronary disease, older age, conduction abnormality, and history of hypertension were associated with elevated risk of dying similarly in both phases (p less than 0.05). Severity of angina symptoms and lower weight were associated with an elevated risk of dying only in the early phase (p less than 0.05; because few of the patients were obese, estimates of the relative risk of morbid obesity could not be estimated), whereas vascular disease, diabetes, and extent of myocardial damage were associated with an elevated risk of dying only in the late phase (p less than 0.05). These data illustrate both the differential influence of risk factors over time and the importance of multiphase models.
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PMID:Determinants of early versus late cardiac death in patients undergoing coronary artery bypass graft surgery. 193 15

Retroaortic crossing of the pedicled right internal thoracic artery for revascularization of the circumflex artery used in combination with a pedicled left internal thoracic artery anastomosed to the left anterior descending artery and its branches is an attractive technique to achieve an extensive arterial revascularization of the left ventricle. However, there is a suspicion that pulling the right internal thoracic artery through the transverse sinus could compromise its blood flow capacity and patency. Between January 1990 and July 1994 this technique was applied in 256 patients (202 men, 54 women; average age 62 years, range 31 to 80 years). Sixty-one patients had two-vessel disease and 195 had three-vessel disease. Seventeen patients were undergoing a reoperation. Twenty-two had a left ventricular ejection fraction of 40% or less. Thirty had diabetes. Twenty-eight had morbid obesity. The right internal thoracic artery was directed to the circumflex artery (259 anastomoses) through the transverse sinus and the left internal thoracic artery was anastomosed to the left anterior descending artery and its branches (375 anastomoses) in all patients. The 195 patients with three-vessel disease received additional coronary artery bypass grafts to the right coronary artery (93 saphenous vein grafts, 89 free inferior epigastric artery grafts, 12 pedicled right gastroepiploic artery grafts). In total, the 256 patients received 833 distal anastomoses (average 3.2, maximum 5 per patient) and 634 distal anastomoses were internal thoracic artery anastomoses (average 2.4, maximum 4 per patient). Three patients died early and eight had a nonfatal myocardial infarction. Seven patients needed postoperative intraaortic balloon pump support. Six patients underwent early reoperation because of excessive bleeding. Sternal dehiscence occurred in four patients. One of these four patients died of the complication 10 months after the operation. No patient was lost to follow-up (average 33 months). During follow-up, two sudden deaths and six noncardiac deaths occurred. Two patients had a nonfatal myocardial infarction and 12 had recurrence of angina. There were no late reoperations. One patient underwent a successful percutaneous balloon angioplasty of a native left anterior descending artery. Seventy-four patients, enrolled in prospective angiographic studies, underwent a postoperative recatheterization (average 13.2 months, range 6 to 58 months). Seventy-three of the 74 right internal thoracic artery grafts were patent. In comparison, 74 of 74 of the left internal thoracic artery grafts (106/107 anastomoses) were patent. Maximal stress thallium-201 scintigraphy results, obtained in 25 of those patients, did not reveal ischemia in the area of the circumflex artery.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Revascularization of the circumflex artery with the pedicled right internal thoracic artery: clinical functional and angiographic midterm results. 747 86

Laparoscopic adjustable gastric banding (LAGB) is gaining popularity as a technique for achieving effective weight loss in the severely obese population. It is a minimally invasive procedure and the reported early morbidity is low. However, we have observed at our institution that occasional patients complain of central chest pain, mimicking angina (verbal pain score of > 7 out of 10), within 2 h after the procedure. This is a worrying symptom because obesity is known to be a major risk factor for developing cardiovascular complications. We have now performed 250 LAGB operations at our hospital. The following four case reports document our patients who presented with early chest pain postoperatively. Common characteristics of male gender, morbid obesity and some degree of obstructive sleep apnoea were identified among the cases. The aetiology of the chest pain is uncertain; nevertheless, close monitoring is vital to exclude pathological events such as acute coronary syndrome.
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PMID:Chest pain in the early postoperative period after laparoscopic adjustable gastric banding: four case reports. 1654 61

Total occlusion of the left main coronary artery predominantly presents with recurrent angina or myocardial infarction. Long-term survival and myocardial function depends on the well-developed right to left collaterals. We report a case of a 46-year-old man who was referred because of incidental finding of low ejection fraction during work-up for syncope 5 months prior. The patient denied any recurrence or any other symptom after that episode and claimed an unchanged exercise capacity. He had hypertension, hyperlipidemia, and history of 15-pack/year smoking. Except for class II morbid obesity, he had completely normal vital signs, physical examination, and lab tests on admission. The echocardiogram was suggestive of previous anterior wall myocardial infarction and demonstrated a low left ventricle ejection fraction with diffuse hypokinesis of the left ventricle. The patient underwent cardiac catheterization, which revealed total occlusion of the left main coronary artery, dominant right coronary artery with a 95% stenosis in the proximal segment, and collaterals from the right to the left coronary arteries. The patient was immediately referred for coronary artery bypass surgery. This case demonstrates the power of collateral circulation in protecting the patient from symptoms and death despite total occlusion of the left main coronary artery and severe stenosis of the proximal right coronary artery.
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PMID:The power of collateral circulation: a case of asymptomatic chronic total occlusion of the left main coronary artery. 2295 76

The objectives of this review were to analyze the literature describing the benefits of minimally invasive gynecologic surgery in obese women, to examine the physiologic considerations associated with obesity, and to describe surgical techniques that will enable surgeons to perform laparoscopy and robotic surgery successfully in obese patients. The Medline database was reviewed for all articles published in the English language between 1993 and 2013 containing the search terms "gynecologic laparoscopy" "laparoscopy," "minimally invasive surgery and obesity," "obesity," and "robotic surgery." The incidence of obesity is increasing in the United States, and in particular morbid obesity in women. Obesity is associated with a wide range of comorbid conditions that may affect perioperative outcomes including hypertension, atherosclerosis, angina, obstructive sleep apnea, and diabetes mellitus. In obese patients, laparoscopy or robotic surgery, compared with laparotomy, is associated with a shorter hospital stay, less postoperative pain, and fewer wound complications. Specific intra-abdominal access and trocar positioning techniques, as well as anesthetic maneuvers, improve the likelihood of success of laparoscopy in women with central adiposity. Performing gynecologic laparoscopy in the morbidly obese is no longer rare. Increases in the heaviest weight categories involve changes in clinical practice patterns. With comprehensive and thoughtful preoperative and surgical planning, minimally invasive gynecologic surgery may be performed safely and is of particular benefit in obese patients.
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PMID:Laparoscopy in the morbidly obese: physiologic considerations and surgical techniques to optimize success. 2410 Jan 46